PART 1: Better Assistive Technology Decision Making

PART 1: Better Assistive Technology Decision Making Through Research By Penny Reed

research

PART 1: Better Assistive Technology Decision Making Through Research

A little over a year ago I overheard a conversation between two of my colleagues who are very knowledgeable about assistive technology (AT). One asked the other if she knew of any research about AT. The reply was, “There really isn’t any research about AT.” I was shocked by that conversation, because there is quite a bit of research regarding AT. It’s led me to research and embark on a mission to help all of us be more aware of the readily available research about AT and how it can inform us as we make decisions about AT for our students with disabilities. This is especially important because federal regulations actu- ally require that our Individualize Education Program (IEPs), in- cluding special education, related services, and supplementary aids and services, be based on peer-reviewed research to the ex- tent practicable (34 C.F.R. §300.320(a)(4)). Since AT is required to be made available, if needed, as part of special education, related services, or supplementary aides and services (34 C.F.R. §300.105), it’s not much of a reach to realize that we need to know about AT research. There is an abundance of research available, and we won’t be able to cover all of it, but included here are some of the key find- ings that every AT Specialist and IEP team member should know. This first article in a two-part series will focus on AT for students with intellectual and low incidence disabilities. Augmentative and Alternative Communication Well Researched One of the most well researched areas of AT is augmentative and alternative communication (AAC). Calculator & Black, (2009) reviewed 102 published articles and identified effective practices for teaching AAC to students, including: • Using naturalistic teaching, • Using a system of least prompts, • Training peers and teachers to use the devices,

• Teaching multiple modes of AAC, • Teaching a single symbol for a variety of purposes, and • Introducing the use of communication devices early in a child’s life. Their literature review also suggests strong evidence for the use of AAC for students with significant intellectual disabilities. The absolute misconception that children must have some type of “pre-requisite skills” before AAC is used is still occasionally heard. However, numerous researchers have disproved the belief that persons with significant levels of intellectual disabilities need to reach a certain performance level or that they could not benefit enough from communication devices to justify the cost (Light, Roberts, Dimarco, & Greiner, 1998; McNaughton, Light, & Arnold,

2002; Romski & Sevcik, 1997; Romski & Sevcik, 2000). Use of AAC Does Not Keep a Child from Learning to Talk

Unfortunately, we still hear of service providers and family members who want to postpone the introduction of AAC because they fear that it will delay the development of the child’s spoken language. Research tells us clearly that the use of AAC, including voice output devices, absolutely does not prevent the develop- ment of speech. Some of the best evidence for this comes from a thorough meta-analysis of the literature by Millar, Light, and Schlosser (2006). They reviewed hundreds of studies, eliminat- ing those that were not well designed. They narrowed their focus down to 23 studies of high quality that involved 67 individuals from ages two to 60. These subjects included individuals identi- fied as having developmental disabilities, intellectual disabilities, mental retardation or autism. They looked at speech production before, during and after the introduction of AAC. They found un- equivocally that AAC use did not slow or prevent the development of spoken language. In fact, speech production increased in 89%

Dr. Penny Reed is an independent consultant who provides consultation and training on a variety of topics related to assistive technology with a special focus on helping school districts improve their delivery of assistive technology services. She is the author of numerous publications about assistive technology services. She can be reached at 1happypenny@gmail.com.

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Use of Power Mobility Another area where some team members may have questions about the use of AT is power mobility. While there is no clear an- swer to exactly when to begin power mobility, multiple studies have demonstrated that children less than two years of age can learn to use power mobility (Butler, Okamoto, & McKay, 1984; Jones, McEwen, & Hansen, 2003; Kangas, 1997; Zazula & Foulds, 1983). Research has not been able to identify a tool that is effective in determining readiness for power mobility. For young children who are not learning to walk at the same age as peers, power mo- bility provides many opportunities to engage in more indepen- dent exploration of their environment, as compared with focusing exclusively on remediation of mobility difficulties, which can de- lay independent exploration. When not exhausted from efforts to move about their environment, children can see, hear and touch elements around them. This is important because exploration is important for spatial searching, spatial problem solving, social and exploratory behaviors, and visual tracking (Gustafson, 1984; Yan, Thomas, & Downing, 1998). No research has substantiated a commonly held fear that chil- dren will regress in motor skills due to use of power mobility (Bot- tos, Bolcati, Sciuto, Ruggeri, & Feliciangeli, 2000; Jones, McEwen, & Hansen, 2003). Parents, who sometimes worry about loss of motor abilities if power mobility is used, have reported: increased child independence and personal control, increased child engagement in meaningful life experiences and positive effect on others’ atti- tudes toward the child when power mobility is provided (Berry, McLaurin, & Sparling, 1996; Wiart, Darrah, Cook, Hollis, & May, 2003). While there was often trepidation prior to beginning to use power mobility, Home and Ham (2003) found the majority of parents who responded to a questionnaire felt that power mobil- ity increased confidence, motivation and happiness, and reduced frustration. AT for Self-Management for Students with Intellectual Disabilities Although there is less research in other areas of AT use for stu- dents with intellectual disabilities, there is evidence that AT can be effective for self-management and self-prompting. Cullen, Alber- Morgan, and Shelia (2015) reviewed 36 studies about using tech- nology mediated self-prompting for daily living skills and found this body of research has demonstrated the positive effects of technology mediated self-prompting for adolescents and adults with disabilities across a range of daily living skills, in a wide variety of settings, and using a variety of types of technology. The most targeted activities for this research were buying, preparing and consuming food. Some focused on managing personal finances, managing a household and buying and caring for clothing. Other researchers have looked at a variety of uses of AT for self-management (Davies, Stock, and Wehmeyer, 2002a; Lancioni, O’Reilly, Seedhouse, Furniss, & Cunha, 2000; Lancioni, et.al., 1998;

of the subjects. There was no evidence of decreases in speech in any subjects. For 11% of the subjects across all studies there was no change, but for 89% of those individuals provided with AAC, their speech production increased. While this meta-analysis was done 12 years ago, it is definitive. We don’t need more research to answer this question any more than we need more research to determine if seatbelts are effective in preventing deaths in car ac- cidents. We know the answer. Don’t expect, or feel a need for, new research to address this issue. What we are beginning to see in research now is that it delves further into why AAC works and how it can be most effectively used. Romski, et.al. (2010) studied 68 toddlers with developmental disabilities. Prior to the start of the study, they had fewer than 10 spoken words each. They randomly assigned them to three groups who were provided AAC for input (receptive language), AAC for output (expressive language) or spoken language intervention only. For the first group, the adult used symbols for the child’s re- ceptive communication, pointing to them when speaking. For the second group, the adult used hand over hand to help the child use a speech-generating device for expressive communication. The toddler’s vocabulary use was checked after 18 and 24 sessions. In both augmented interventions the children made modest, but significant gains. Children receiving spoken intervention only and no AAC did not make any gains. The toddlers who received AAC for output were much more likely to produce spoken words. The toddlers who received AAC for receptive communication also made gains in their use of spoken words. This research tells us that AAC Intervention with young children with developmental delays actually facilitates the development of speech better than spoken language intervention alone. Look for more research along these lines as researchers begin to identify specific aspects of AAC use that are important. The Greatest Challenge in Teaching Children to Use AAC Several studies show that the greatest challenge to successful AAC intervention is in training communication partners. Research by Binger et al., (2010); Kent-Walsh et al., (2010) Cumley & Beukel- man, (1992); Light, Collier, & Parnes, (1985) shows that communi- cation partners tend to: • Dominate communication interactions; • Ask predominantly yes or no questions; • Take the majority of conversational turns; • Provide few opportunities for the child to initiate or respond; • Interrupt the child’s communicative attempts; and • Focus too much on the technology tool. The ImPAACT Program (Kent-Walsh & Binger, 2013) is one in- tervention program that has been documented to yield positive results for clients using AAC. https://www.researchgate.net/pub- lication/260124160_Fundamentals_of_the_ImPAACT_Program

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Lancioni, et. al., 1999). They found that picture cues presented digi- tally are more effective than pictures presented manually on cards and that personal computer systems with auditory prompts and text are more effective than traditional written schedules. Mech- ling (2007) found digital devices to be effective to self-initiate, self-instruct, self-maintain and self-monitor one’s behavior and task performance. AT has been found to be very effective as a self- management tool. AT for Reading for Students with Low incidence Disabilities There is often a presumption that students with significant disabilities including intellectual disabilities will not learn to read. When present, this presumption can lead to the denial of reading instruction, which results in students not learning to read (Keefe & Copeland, 2011; Ruppar, Gaffney, & Dymond, 2015). Much of the research on reading for students with severe disabilities in the past has been focused on sight word memorization or drills in decontextualized sub-skills. That research will not be reviewed here. Rather, we’ll look at the research about the broader reading and writing experiences that lead to the development of literacy skills (Erickson, Hanser, Hatch, & Sanders, 2009; Erickson, Hatch, & Clendon, 2010). For example, when children write, they attempt to read what they have written. If an adult asks the child what he or she wrote, the child will explain it. Speaking and listening occur as part of the overall literacy experience. Effective literacy instruc- tion has been shown to develop the traditional reading/literacy skills for children with significant disabilities, including intellectual disabilities. An excellent free resource about effective literacy in- struction is Erickson, K., Hanser, G., Hatch, P. & Sanders, E. (2009). Research-Based Practices for Creating Access to the General Curricu- lum in Reading and Literacy for Students with Significant Intellectual Disabilities , https://www.kcdsg.org/files/content/Cheryl%20Jor- gensen_Literacy%20and%20Severe%20Dis.pdf. Access to Information vs. Access to Learning Rose and Meyer (2002) were the first to make a distinction be- tween access to information and access to learning. The distinc- tion is important because providing quick access to information may decrease the opportunity for a child to learn new skills and thus have more access to learning. The use of picture supported text is an example of this. Hatch (2009) found that it may actually increase confusion, limit literacy learning in the long run, and in- terfere with learning opportunities. Several studies have conclud- ed that placing pictures with text slows the rate of word learning (Pufpaff, Blischak, & Lloyd, 2000; Rose & Furr, 1984; Saunder & Sol- man, 1984). While picture supported text may provide access to content information, it may actually impede the more long term learning of reading and other literacy skills. That is not to say that there is no place for the use of picture supported text, but rather to know that its use will not automatically lead to the development

of decoding skills. Picture supported reading and writing can be very useful and may be chosen as the best means for a student to access information and communicate in writing, but it’s not a scaf- fold to the development of traditional literacy skill. One reason for this may be the actual figure (printed word vs. picture symbol) on which the eyes and the child’s efforts are focused. There are many components to literacy and they involve focusing on the building blocks of reading and writing. One small study provides a glimpse of the importance of invented spelling and later reading skill. Ouellette and Senechal (2017) found that alphabetic knowledge and phonological awareness are developed through practice. If a student does not practice using letters to represent sounds when writing or work to decode printed letters to make meaning, those skills will not develop. AT Use by Adults with Significant Intellectual Disabilities (ID) It appears that AT can be effective in the workplace. Morash- Macneil, Johnson, & Ryan (2017) found AT was successful for in- creasing work performance of individuals with ID in respect to productivity, navigation, time management and task completion. Cullen, Alber-Morgen, & Sheila (2015) found that prompting with AT is more effective than low tech methods and Sauer, Parks, & Heyn (2010) found that AT results in increases in accuracy, inde- pendence and generalization. Similarly, Sauer et al. (2010) indicat- ed that following the implementation of AT, there was an increase in accuracy, independence and generalization of skills in the work- place. Technology in these studies included hand held computers, iPads, iPods, smart phones and vibrating watches. In other research, Bryant, Seok, Ok, & Bryant (2012) surveyed care givers and found that the majority of clients were not us- ing AT devices to support their needs in identified areas of living (home living, community living, life-long learning, employment, health & safety, social, protection & advocacy). In four of the seven areas, at least 60% of clients were not using AT devices as part of their support system. This research is several years old and hope- fully, this picture will change as use of AT becomes more pervasive. Part Two: Research on AT use by Students with High Incidence Disabilities This has been a brief overview of some of the valuable research about AT. Part 2 of this two-part series will look at research about AT use by students with high incidence disabilities, where the focus is primarily on reading and writing. Resources to continue to keep informed about AT research will also be included. In the meantime, consider visiting www.natenetwork.org/resources where ongoing information about AT Research is frequently up- dated.

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References Berry, E. T., McLaurin, S. E., & Sparling, J. W. (1996). Parent/caregiver per- spectives on the use of power wheelchairs. Pediatric Physical Therapy, 8, 146-150. Binger, C., Kent-Walsh, J., Ewing, C., & Taylor, S. (2010). Teaching edu- cational assistants to facilitate the multi-symbol message productions of young students who require AAC. American Journal of Speech-Lan- guage Pathology, 19, 108–120. Bottos, M., Bolcati, C., Sciuto, L., Ruggeri, C., & Feliciangeli, A. (2001). Powered wheelchairs and independence in young children with tetraple- gia. Developmental Medicine and Child Neurology, 43, 769-777. Bryant, B. R., Seok, S, Ok, M., & Bryant, D.P. (2012). Individuals with in- tellectual and/or developmental disabilities use of assistive technology devices in support provision. Journal of Special Education Technology, 27(2), 41-58. Butler, C., Okamoto, G. A., & McKay, T. M. (1984). Motorized wheelchair driving by disabled children. Archives of Physical Medicine and Child Neu- rology, 25(4), 472-474. Calculator, S. N., & Black, T. (2009). Validation of an inventory of best practices in the provision of augmentative and alternative communica- tion services to students with severe disabilities in general education classrooms. American Journal of Speech-Language Pathology, 18, 329- 342. Cullen, J. & Alber-Morgan, M. & Shelia, R. (2015). Technology Mediated Self-Prompting of Daily Living Skills for Adolescents and Adults with Dis- abilities: A Review of the Literature. Education and Training in Autism and Developmental Disabilities, 50(1), 43–55 Cumley, G. D., & Beukelman, D. (1992). Roles and responsibilities of facilitators in augmentative and alternative communication. Seminars in Speech and Language, 13, 111–118. Davies, D. K., Stock, S. E., & Wehmeyer, M. L. (2002a). Enhancing inde- pendent time-manage ment skills of individuals with mental retardation using a palmtop personal computer. Mental Retardation, 40, 358-365. Erickson, K., Hanser, G., Hatch, P., & Sanders, E., (2009). Research-Based Practices for Creating Access to the General Curriculum in Reading and Literacy for Students with Significant Intellectual Disabilities. Center for Literacy and Disability Studies, University of North Carolina at Chapel Hill. https://www.kcdsg.org/files/content/Cheryl%20Jorgensen_Literacy%20 and%20Severe%20Dis.pdf Erickson, K. A., Hatch, P., & Clendon, S. (2010). Literacy, assistive technol- ogy, and students with significant disabilities. Focus on Exceptional Chil- dren, 42(5), 1-16. Gustafson, G. E. (1984). Effects of the ability to locomote on infants’so- cial and exploratory behaviors: An experimental study. Developmental Psychology, 20, 397-405. Hatch, P. (2009). The effects of daily reading opportunities and teacher experience on adolescents with moderate to severe intellectual disability. Unpublished doctoral dissertation, University of North Carolina at Chapel Hill. Home, A. M., & Ham, R. (2003). Provision of powered mobility equip- ment to young children:TheWhizz-Kidz experience. International Journal

of Therapy and Rehabilitation, 10, 511-518. Jones, M. A., McEwen, I. R., & Hansen, L. (2003). Use of power mobil- ity for a young child with spinal muscular atrophy. Physical Therapy, 83, 253-262. Kangas, K. M. (1997). Clinical assessment and training strategies for the child’s mastery of independent powered mobility. In J. Furumasu (Ed.), Pe- diatric powered mobility: Developmental perspectives, technical issues, clinical approaches (pp. 33-47). Arlington, VA: RESNA/Rehabilitation Engi- neering and Assistive Technology Society of North America. Keefe, E. B., & Copeland, S. R. (2011). What is literacy? The power of a definition. Research and Practice for Persons with Severe Disabilities, 36 (3-4), 92–99. Kent-Walsh, J., & Binger, C., (2013). Fundamentals of the ImPAACT Pro- gram. Perspectives on Augmentative and Alternative Communication. April, 2013, 51-61 downloaded November 2016 https://www.research- gate.net/publication/260124160_Fundamentals_of_the_ImPAACT_ Program Kent-Walsh, J., Binger, C., & Hasham, Z. (2010). Effects of parent instruc- tion on the symbolic communication of children using AAC during sto- rybook reading. American Journal of Speech-Language Pathology, 19, 97–107. Lancioni, G.E., O’Reilly, M.F., Seedhouse, P., Furniss, R., & Cunha, B. (2000). Promoting independent task performance by persons with severe devel- opmental disabilities through a new computer-aided system. Behavior Modification 24,5, 700-718. Lancioni, G.E., O’Reilly, M.F., Van den Hof, E., Furniss, R., Seedhouse, P. & Rocha, N. (1999). Task instructions for persons with severe intellectual Dis- ability: Reducing the number of instruction occasions after the acquisi- tion phase. Behavioral Interventions 14, 199-211. Lancioni, G.E., Van den Hof, E., Boelens H, Rocha, N., & Seedhouse, P. (1998). A computer based system providing pictorial instructions and prompts to promote task performance in persons with severe develop- mental disabilities. Behavioral Interventions 13, 111-122. Light, J., Collier, B., & Parnes, P. (1985). Communicative interaction be- tween young nonspeaking physically disabled children and their prima- ry caregivers: Part 1: Discourse patterns. Augmentative and Alternative Communication, 1, 74–83. Light, J., Roberts, B., Dimarco, R., & Greiner, N. (1998). Augmentative and alternative communication to support receptive and expressive communication for people with autism. Journal of Communication Dis- orders, 31, 153-180. McNaughton, D., Light, J., & Arnold, K. B. (2002). “Getting your wheel in the door”: Successful full-time employment experiences of individuals with cerebral palsy who use augmentative and alternative communica- tion. AAC Augmentative and Alternative Communication, 18(2), 59-76. Mechling, L. C. (2007). Assistive Technology as a Self-Management Tool for Prompting Students with Intellectual Disabilities to Initiate and Complete Daily Tasks: A Literature Review. Education and Training in De- velopmental Disabilities, 42(3), 252-269 Millar, D., Light, J.C., & Schlosser, R.W., (2006). The impact of augmenta- tive and alternative communication intervention on the speech produc-

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tion of individuals with developmental disabilities: A research review. Journal of Speech, Language, and Hearing Research, 49(2), 248-264. Morash-Macneil, V. Johnson, F., & Ryan , J.B. (2017). A systematic review of assistive technology for individuals with intellectual disability in the workplace. Journal of Special Education Technology Ouellette, G. & Sénéchal, M. (2017). Invented spelling in kindergarten as a predictor of reading and spelling in Grade 1: A new pathway to liter- acy, or just the same road, less known? Developmental Psychology 53(1), 77-88. Pufpaff, L.A., Blischak, D.M. & Lloyd, L.L. (2000). Effects of modified or- thography on the identification of printed words. American Journal on Mental Retardation, 105(1), 14-24. Romski, M.A., & Sevcik, R.A. (1997). Augmentative and alternative com- munication for children with developmental disabilities. Mental Retarda- tion & Developmental Disabilities Research Reviews, 3(4), 363-368. Romski, M.A., & Sevcik, R.A. (2000). Communication, technology, and disability. In M. Wehmeyer & J.R. Patton (Eds.), Mental Retardation in the 21st Century (pp. 299-313). Austin, TX: Pro-Ed. Romski, M.A., Sevcik, R.A., Adamson, L.B., Cheslock, M., Smith, A., Barker, R.M., & Bakeman, R. (2010). Augmented and nonaugmented language interventions for toddlers with developmental delays and their parents. Journal of Speech, Language, and Hearing Research 53, 350-364. Rose, D., & Meyer, A., (2002). Teaching every student in the digital age:

Universal design for learning. Alexandria, VA: Association for Supervision and Curriculum Development. Rose, T.L. & Furr, P.M. (1984). Negative effects of illustrations as word cues. Journal of Learning Disabilities, 17(6), 334-337. Ruppar, A.L., Gaffney, J.S., & Dymond, S.K. (2015). Influences on teach- ers’ decisions about literacy for secondary students with severe disabili- ties, Exceptional Children 81(2), 209-226. Sauer, A.L., Parks, A, Heyn, P.C. (2010). Assistive technology effects on the employment outcomes for people with cognitive disabilities: A sys- tematic review. Disability and Rehabilitation, 5, 377-391. Saunder, R.J., & Solman, R.T. (1984). The effect of pictures on the acqui- sition of a small vocabulary of similar sight-words. British Journal of Educa- tional Psychology, 54(3), 265-275. Wiart, L., Darrah, J., Hollis, V., Cook, L., & May, L. (2004). Mothers’percep- tions of their children’s use of powered mobility. Physical and Occupation- al Therapy in Pediatrics, 24 (4), 3-21. Yan, J.H., Thomas, J.R., & Downing, J. H. (1998). Locomotion improves children’s spatial search: A meta-analytic review. Perceptual and Motor Skills, 87, 67-82. Zazula, J. L., & Foulds, R. A. (1983). Mobility device for a child with pho- comelia. Archives of Physical Medicine and Rehabilitation, 64, 137-139.

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