Through the Occupational Therapy Lens

Through the Occupational Therapy Lens by Froma Jacobson

perceptual-motor access

Through the Occupational Therapy Lens Froma Jacobson is an Assistant Professor for Midwestern University’s Occupational Therapy Program. She received her Bachelor of Science degree in Occupational Therapy in 1970 at the University of Southern California and her Master in Education from Arizona State University in 2003. Her practice has included direct client service, program development, systems change, management with supervision, product development and teaching pre-service students and post-service professionals. This visionary imagined, developed and directed the AT service delivery model at the Arizona Department of Education and was a founding member of of State Leaders of Assistive Technology in Education. She is recognized as a pioneer (since 1976) in the development and implementation of the role of Occupational Therapy in Augmentative Communication and later in all the Assistive Tech- nology solutions available to adults and children. She has presented at numerous local, state, national and international conferences and post graduate educational venues on various topics pertaining to the role of Occupational Therapy in Assistive Technology and Universal Design. The professional community recognized froma as the recipient of the Arizona Occupational Therapy Association Distinguished Achievement Award in 1997 and the Arizona Council for Exceptional Children for Distinguished Service to Exceptional Children in 1991. Ms. Cummings began her career at Midwestern University in 2009 following her position as Clinical Associate Professor and Coordinator of the Certificate in Assistive Technology and Accessible Design at the University of Wisconsin, Milwaukee.

Occupational Therapy (OT), my cho- sen profession, has recently celebrated our centennial year, and I am fortunate to have been practicing for almost half of that. My engagement in the equally broad field of Assistive Technology began on February 4th, 2976 and continues to evolve. Please allow me the opportunity to reminisce on what I consider the three stages of my developing professional journey and the role OT has played and continues to play on the transdisciplinary team for persons whose engagement in meaningful occupation can be enhanced by specialized technology. Stage 1 I hopped into the golden opportu- nity to look at Assistive Technology (AT) through the OT lens in 1976 as a young clinician working at Plavan School at Fountain Valley California when Dr. Judy Montgomery, PhD., SLP-CCC successful- ly wrote the grant to open the Non Oral Communication Center. Understanding the infancy of AT as we know it today and the confusion about OT, I, at that time, at- tempted to write an article bringing un- derstanding to the role of OT on the team. This article, included here in its entirety, was published in the Zygo Resources Magazine circa about the 1979.

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These ideas were further developed in a chapter I authored in 1985. Yet again, in 1989 I reiterated what we had learned in the past 10 years – essentially the same best practices focusing on the ‘new developing technol- ogy of the times.’ You will note that my name has evolved from Sadacca to Jacobson.

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(Cummings, f. 1989)

In review today, thinking back at the development of our field and my experiences working at such centers as the Non Oral Communication Center with Judy, Loma Linda University with Mel Cohen, Systems and Programs to Enhance Augmentative Communication (SPEAC) at Upward Foundation Phoenix with Mary Christen, Zygo Industries and moving forward, the role of OT as a team member has not significantly changed. Stage 2 Fast forward to 2005: I am now the Director of Assistive Tech- nology and Accessible Instructional Materials at the Arizona De- partment of Education. Our service delivery model, not dissim- ilar to other statewide delivery programs such as WATI, PIAT and TATN, was to service the needs of the children through building capacity in school personnel. Individualized education program (IEP) team members were struggling to consider the need for Assistive Technology for all students during the IEP process, and at the state level, we attempted to supplement team trainings with ‘easy to do’ ways to advocate for students. I carried the chal- lenge forward, attempting to create a way OTs could effective- ly look at a student and make meaningful contributions – even an OT who did not share my passion for AT. In 2007, I joined the faculty at University of Wisconsin-Milwaukee and partnered with Dr. Shelley Lund to develop a speech and language pathol- ogy and occupational therapy team at Milwaukee Center for In- dependence. While working with her, Dr. Roger Smith and Dr. David Edyburn, I continued to brew the idea of a cheat sheet summary for OTs working with persons with complex communi- cation needs. In February of 2010, while teaching at Midwestern University – Glendale, I collaborated with the AT team (Barbara Hendrickson, OTR/L and Jolene Madden M.Ed., CCC-SLP) in the Scottsdale Unified School District to develop and disseminate the following protocol:

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Stage 3

calibration had become misaligned when her new head support was placed, and she had been rejecting the system since she perceived that it no longer worked for her. This was in spite of all the efforts from the Gompers staff, professionals and caregivers to recalibrate the system and make her device and expressive language available to her. My observations, through my OT lens and thoughts previously described regarding perceptual motor access, saw possibilities for scanning that could potentially af- ford faster communication and easier, more fail-safe set-up in the environment. I suggested the possibility and educated as best I could: In the climate of disappointment and unsuccessful access, Laroncita did not yet trust me and we ended our time together. One week later, after additional collaboration, the yet more determined Candice and froma tag team (OT and Speech) re-ap- proached. Laroncita also had had time to reconsider her access and need for reliable repeatable access methods to meet her communication needs through the day and across all areas of occupation. When she gave us the go ahead to show her ad- ditional access methods, it was all systems go full steam ahead. Within 45 minutes, she had a second access method, which at this emerging stage was faster and more client satisfying than her initial method; one switch row column scanning with dwell including a rigid mount for the device, flexible mount for the switch and micro light switch to the left side of the face. Professionally relinquishing all roles in the client-centered arena, Laroncita, her body (posturing, tone and reflexes) cou- pled with her communication needs, guided the process. The professional brain goes on automatic, drawing on the evidence and professional experience. I would like to think I reflected and professionally referred to the articles otherwise referenced and the Occupational Therapy Practice Framework, but all I could think is “Laroncita is trusting us to get this right and we better surpass her expectations!’ This is the process and professional reasoning as per best recall: 1. Visually scan the environment and understatedly gather en- thusiasm and support: This is the team ultimately respon- sible for making communication available to Laroncita on a daily basis. 2. Appreciate and respect my professional partner, fully un- derstanding that she and the client are trusting my eyes and professional experience. This is done with the mutual re- spect that I bring fresh eyes/thinking, and she is the expert on the client and what is pragmatically available within the environment. 3. Watch and observe. At this junction, my eyes watched the member’s tone, reflexes, motions and motor patterns as we engaged in no tech total communication strategies. While her gross posture shifted and she appeared to demonstrate numerous unintentional motions, she seemed to have reli- able, intentional, repeatable ability to move her head to the side and to the left. It also appeared that she could return to

I met Laroncita when I was at Gompers Habilitation Center, Phoenix, Arizona, visiting with the members to gather occupa- tional narratives as part of a case study project in a community based learning environment for my graduate level OT students at Midwestern University - Glendale. Candice M. Steel, SLP-L, ATP and I were teaming to demonstrate the transdisciplinary approach within the SETT mindset to enhance engagement in meaningful occupations with persons who use augmentative and alternate communication strategies. Having known Laron- cita from previous visits, I expected she would be using eye gaze to input her AAC device. Prancing towards the area I expected to find this self-directed woman, I so eagerly expected an interaction that would provide my graduate students insight into the intentional relationship and example after example of how this member enjoys and par- ticipates in activities across all areas of communication. Instead, we found a young woman sitting asymmetrically in her wheel- chair, without her device or mounting system: Her head was supported by a pillow placed about six weeks previously and her communications were limited to no tech strategies. Candice and I tag teamed, demonstrating complete role transparency had there been a trained observer and explaining the purpose of our visit to Laroncita, while attempting to under- stand rationale for the absence of her device. She, using total communication strategies, told us she did not want to speak with us and did not want to use her high tech eye gaze input system. Candice and I respectfully listened but picture three self-directed persons in this interaction, two trying to under- stand ‘what is going on here and how can we fix it?’ Laroncita, through education and advocacy attempts from the profession- als, acquiesced and allowed us to charge and mount her device that we found in the transport bag across the room. Through the discovery process, we concluded that her eye

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the original position without extraneous moments or over- flow in other area of her body. 4. We explained to Laroncita what we thought her body was telling us and asked permission to go to the next step. With her permission, I held my hand to the left side of her face and asked that she touch it on command. She seemed to do this effortlessly, with minimal delay, and ability to return to neutral position. 5. Again, with permission, we offered a switch. We did not have access to a full range of switches but did find a minimalist switch. The member, at this point onboard and apparent- ly hopeful, reliably, repeatedly and with minimal fatigue accessed the switch, searched for it as necessary, released and returned to midline and retouched seamlessly and with intentionality. 6. The next stage was to mount the interim switch to guaran- tee that the overzealous I, who at this point was doing the happy dance, was not responsible for the accurate timely hit/release patterns we had observed. We located sufficient sections of the flexible modular hose mounting with mount plate (plate was larger than preferred but that which was available). While I held the switch, Candice got it positioned just right and we both stood back: Laroncita demonstrated continued and continuing ability to hit and release a single switch to the left of her face. Overflow and fatigue were not factors. 7. The familiar device was mounted at eye level for scanning, not to block eye contact for communication and navigation through the building. Laroncita was previously familiar with the communication targets and layouts, and this hastened mastery. After minutes communicating using simple scan- ning, she quickly progressed toward single switch row col- umn scanning with dwell. Although the OT - SLT ATP team may have moved her to a more complex speed enhancing scanning array, row column scanning was the client’s pre- ferred array. She spoke for over twenty minutes with full attention to the screen – she even spoke while we were set- ting up the system! 8. Laroncita quickly spoke “I am excited” and asked to be taken to see her favorite care provider in another room. This per- son was absent that day, but the member initiated conver- sation with everyone she saw on the way!

A). Person with motor access challenges and complex communication needs.

B). Note communicative intent and total communication strategies, while Candice Steel, B.S., SLT, ATP is re-calibrating eye gaze input.

C). Example of page she had previously accessed using eye gaze.

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D). Screen showing eye gaze calibration: What follows is transdisciplinary conversation if eye gaze, head pointing or scanning OR combination of will afford greater communication opportunities and what the client’s environments can consistently support.

F). Watching the client, her movements, intentionality, excursion, tone, reflex patterns, etc., while at the same time thinking forward about switch selection and possible mounting.

G). More watching while using the intentional relationship to build trust and educate the team.

E). Head pointing is trialed next in response to client’s preference in combination with perceived ability of classroom personnel to set up each day. Note that device is not mounted yet. Instead, OT and ST are assessing placement to maximize opportunities for successful access.

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H). Access site for initial attempts at row column scanning has been determined by using clinician’s hand prior to switch. This switch has been chosen because of its lightness and availability. Clinician is demonstrating before asking permission to place switch to the side of the client’s face.

J). Note how her body has relaxed as the task became more familiar. Her speed and expression is greater than she had achieved using eye gaze. Laroncita independently left her communication pages and launched YouTube. Staff members gravitated over to see what was occurring, so we achieved buy-in through her success and ongoing attention to task.

I). Within the first five minutes, client initially hit and released the switch to accurately hit the intended choices without overflow. She used total communication strategies, including the device, to say she was happy. She added speed, self- corrected and combined targets to create longer sentences. She did not want to add an extra switch to make a choice and her preferences were respected, though she was educated about other possibilities.

K). We created a temporary mount – we were not yet convinced that the placement was exact but the client was so excited that she spoke throughout the process and hurried us so she could go talk to someone in another room. She initiated conversation with everyone she saw along the way. Note her relaxed body posture.

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As an academic, I cannot help but reflect on all the learning opportunities from this short scenario:

1. Trust yourself, your scope of practice, the evidence behind our professional bodies of research and what we have learned from the professionals and clients with whom we have interacted. Ethically and assured that you are doing no potential harm, use what you are seeing to give your client all that you’ve got. 2. Respect the importance of the environment - seek support and buy-in from all the players for the benefit of your client. Know what you don’t know and seek help and collaboration from resources in your physical and virtual communities. 3. Be client centered - invoke the intentional relationship to educate but always inform, problem solve, advocate and ask permission. 4. Whereas AT may seem like a specialty, reflecting back to the OT scope of practice traced as far back to my initial thoughts in the Zygo Resources article, this is exactly what we do. It’s reflected throughout the OTPF. 5. And lastly, for anyone who thinks they will “not do AT,” kindly be advised that person after person will come to you in your broad scope of practice who are users of no tech through high tech devices - it’s our professional responsibility to be informed. Reference: Cummings, F. (1989). Children with communicative impair- ment. In P. Nuse Pratt and A. Stevens Allen (Eds.), Occupational therapy for children, (2nd ed., pp. 442- 456). St. Louis, MO: Mosby. Jacobson-Sadacca, F. (1985). Children with communicative impairment. In P. Nuse Clark and A. Stevens Allen (Eds.), Occupational therapy for children (pp. 349-358). St. Louis, MO: Mosby. In closing, thank you so sincerely to all of you who have and continue to contribute to my journey to live and assist others to live life to the fullest using no tech through high tech strategies amongst all the various tools in my OT toolbox.

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