“What do you want to talk about?”- Therapist’s goals vs Individual’s goals.

A few years ago, I had a major rethink about how I set targets for the students who I work with. Previously, targets were based on assessments, functional goals and discussions with parents and school staff. That sounds logical, right?!

I then found myself in a situation where I was working with a student using an AAC device who I felt was disengaging with therapy. No amount of fun, all-singing, all-dancing sessions were cutting it! I tried supporting them in the classroom instead, but found that the same issues existed in that environment and also with different communication partners. Scratching my head, I began digging into research, starting by exploring the Means, Reasons and Opportunities model (Money and Thurman, 1994).

If you’re not familiar with the model, it basically explains the reason why any of us communicate! Firstly, we need a means of doing so- speaking, signing, using a communication book or device. Next, we need opportunities to do so- people to chat with, communication friendly environments and topics of interest! Finally, we need reasons to communicate- to make choices, reject things that we don’t want, ask questions, tell stories, etc!

When we consider the three different aspects of the model, barriers to communication can appear at any level. As SLTs we are trained in identifying what those barriers might be- But our perception might be different to that of the person we are working with!

During this period of research, I stumbled on a fabulous piece of work by the Barnsley Assistive Technology team back in 2010. It’s like a symbolised questionnaire for AAC users based on the Means, Reasons and Opportunities model. You can download it for free here: https://www.barnsleyhospital.nhs.uk/assistive-technology/resource/means-reasons-opportunities-aac/

I immediately wanted to try it out with my teenage student. I adapted it slightly into a Talking Mats style format so that it was really led by the student. The outcome was fascinating…. It transpired that there were issues at every level of the model:

1. Means- using the communication aid was difficult when the student felt tired,
2. Opportunities- conversations could be too fast paced to join in with,
3. Reasons- the student’s main reason for wanting to communicate was to gossip with friends! Without the right vocabulary and pre-stored phrases, this was impossible!

An example of how the resource can be used in a Talking Mat style!

This information gave us a clear plan as to what we needed to do next- 

1. Find an alternative, quicker means of communication for different situations, 

2. Train communication partners in the ‘power of the pause’,

 3. Create ‘Gossip’ pages for the device with useful words and phrases.

I had never included the word ‘gossip’ in a target before (!) but just using that word reminded me of a key aspect of our role- we support others to communicate about what they want to communicate about. Otherwise, what is the point?!

After this revelation, I began ensuring that all my assessments took into account the students’ perspective across all 3 areas of the model (where possible!) but also that they could actively choose at least one of their communication targets. As a result, students are much more engaged and also make incidental progress in other areas.

I’ll give you an example- A young man chose ‘telling jokes’ as something he wanted to prioritise working on. This 100% fitted his personality but in my head I was thinking, “But we still need to work on initiating communication”.  My ‘therapy brain’ had missed the obvious- to tell someone a joke, we need to firstly gain their attention. The student was much more motivated to do this when he felt he had a reason to initiate communication!

An interesting study by Rohde et al (2012) found that the goals of the therapist vs the goals of the client (in this case, adults with Aphasia) often differ. As SLTs we can be impairment focussed or we might not see how the individual’s goal fits our remit. I am not a comedian by any means (!) but working on joke telling was less about the quality of joke and more about social interaction and turn-taking! If a goal is important to the individual, we need to value that and not impose our own agenda. An individual will ALWAYS make more progress with a goal they are invested in as opposed to a goal someone else feels is good for them!

Maybe my student will go on to follow in Lost Voice Guy’s footsteps?!

Changing how I SET goals has also made me consider how I EVALUATE goals. About a year ago, I started using Goal Attainment Scaling (I may need to blog about this in more detail another day!). The idea is that when you review goals, you give them a numerical value as to progress made with the target. The great thing about this system is that it can also involve working with the individual to self-evaluate how they are meeting their goals. Working with students with complex needs, I tend to show them a simplified visual of 2 symbols to select from- ‘I can do it’ or ‘I need more help’. Sometimes our evaluations don’t match but that’s ok- it allows me to consider why they don’t match and how we might tweak the target based on that outcome.

In closing, I thought I’d review the statement that I made at the start of this post: “Previously, targets were based on assessments, functional goals and discussions with parents and staff. That sounds logical, right?!”

My new answer is: Partially! But first of all, what does the individual want to be able to talk about?! That’s where the journey begins! 

P.S. A little bit of blatant self promotion…. I now offer supervision for SLTs. Happy to discuss and help with all things AAC!

“Battery Low!”- Communication aids and cognitive fatigue

Recently while working alongside an Occupational Therapist, I learned about something called ‘Spoon Theory’. This might sound like a fancy new way to sort cutlery, but it’s actually a tool that people with chronic illnesses use to measure the amount of energy daily tasks will take. The idea is that a person might start their day with 12 ‘spoons’ in the drawer, but having a chronic illness can cause fatigue that quickly uses up those spoons.

This is a little example of spoon theory, showing how each task uses up a certain amount of energy:

You might be wondering how does this relate to children who use alternative forms of communication (AAC)?! Well, have you ever worked with a child who seems to use their communication aid or book in bursts? At times they might seem eager to chat to those around them but after a period of time may become uncommunicative, disinterested or downright frustrated. Why? Maybe they’ve run out of spoons!

Using a communication aid involves a few more challenges than automatic speech. Looking at a screen or a book can be tiring; engaging motor skills and searching for a word can be time-consuming ; timing your response to a fast paced conversation can be an absolute nightmare! It seems fitting that aspects of spoon theory might apply to people who use AAC too.

I thought about how I could apply this to the children who I work with so I started by listing all of the elements involved in using an alternative form of communication… gradually this turned into something that I like to call Battery Theory!

Let’s say a child starts off with 12 bars of battery and each of the tasks below depletes a number of bars. Every child will be slightly different so this is just an example. One child might find the social side of communication easy, but become totally exhausted by constructing sentences. Another child might work the opposite way round; you may want to adapt the premise and apply it to a child who you work with. This is what my version looks like:

When a child has used their 12 bars, it’s likely that their ‘battery’ will be flat and they won’t be too enthusiastic about carrying on a conversation. It’s important that we begin to gauge how quickly a child may be ‘running on empty’…and perhaps more importantly, how we can a) help to conserve their battery, and b) boost their battery!

Conserving Battery

• Ensure access is the easiest means possible– Some children struggle with the fine motor skills required to access a communication aid. Instead, they might use fist pointing, a switch or perhaps eye-pointing. On a number of occasions I’ve had conversations with people who have said, “It’d be good if he could use his left hand as his physio target is to use that hand more”….But this is making communication so much more effortful, adding in an extra layer of difficulty! Always look for the easiest, least tiring access method! Some children may have multiple methods- e.g. they might use fist pointing when they have lots of energy and change to eye-pointing when they get tired.

• Ensure frequently used words and phrases are easy to access– I’m sure you’ve heard me mention core vocabulary before (those key words that are used again and again!)- These need to be readily accessible but also consider having a ‘Quick Chat’ page with frequently used stored phrases. You might want to include phrases that ‘buy time’ like “I have something to say” or “Give me a minute”.
• Motor planning– To prevent a time-consuming search for words, try to make sure that words that appear on multiple pages are always in the same location e.g. ‘more’ might be on the top right of each page. This helps the child to develop a motor plan so that retrieving a word becomes almost automatic!
• Allow time to practice new vocabulary or skills in 1:1 sessions or with a friend– Learning and using new skills can be tough, especially in a busy classroom environment. Setting aside some time to practice new skills in short bursts either on a 1:1 basis or with a friend can make it easier. Don’t expect a child to instantly use their new skills or vocabulary in conversations- it can take time to embed and become natural.

Battery Boosting!

• Use a total communication approach e.g non verbal yes/no- Most of the children who I work with have multiple means of communication….and quite often, they will switch between these means within one interaction, depending on what’s easiest or how they feel. Try to find a non-verbal yes/no that the child can use for quick interactions (e.g when they are upset or tired). If a child has a high tech communication aid, always have a paper based back-up. Continuous screen use can be exhausting!!

• Provide Breaks- One thing that Spoon Theory has taught me is that if I want to replenish my spoons, I need to rest. This is exactly the same for Battery Theory! Think of it as ‘charging time’ and follow the child’s lead. Ask them if they want a break or build in ‘down time’ activities where the child can listen to music or read or book as a way of recharging!

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I saw a quote recently that said, “Almost everything will work if you unplug it for a few minutes…including you”. I definitely think that’s good advice for both ourselves and the kids who we work with!

On the other side- Being an impatient patient as a Health Professional

As a Speech and Language Therapist, I’ve become very used to the health professional/service user relationship during my 10 years of practice. I remember role-playing these scenarios as a student SLT, which seems a million miles away now that it has become almost second nature. Over time, you feel as though you can better understand the concerns and needs of the people you are working with, which in my case is children with communication difficulties and their parents.

In actual fact, there is no way to really appreciate how it can feel to be a service-user (or patient) until you or a close loved one ends up in that position. Everyone’s experience may be different but ultimately there are emotions that are difficult to explain if you have never had to hand control over to a group of strangers (i.e. health professionals!). This realisation abruptly came to me when I ended up on the other side of the relationship following a trip to A&E which resulted in a 4 week hospital stay.

In that month, I learned that I am not the patient I thought I would be. I was impatient, inquisitive, frustrated and determined. Sometimes these traits were helpful, sometimes not so much. I now understand that my responses were perfectly normal in relation to my situation. Suddenly I had a new surge of empathy for parents who had come for meetings with a list of questions scribbled in a notepad for me; I felt a rush of sadness for those who had sent me emails late at night, coming from a place of pure desperation.

I currently have some time off work to recover which has also given me time to reflect on some of my experiences, particularly the health professional/service user relationship. I started to think about the things that patients want health professionals to know and consider. Some of these may be obvious, but yet sometimes it is small, seemingly apparent things that are over-looked when rushing between appointments. So my advice to me (as a health professional) from myself (as a patient!) is as follows…

1. Involvement is Empowerment– We all know that it’s good practice to set joint goals. Yet as health professionals, we can often secretly come along with our own agenda or expectations. When I ended up in a hospital bed, I found that some health professionals didn’t always ask for my opinion, while others quite expertly placed my targets at the centre of their care (take a bow, Physios!!). You can imagine which professionals I responded best to! When I was asked to prioritise goals, given a diary to fill with positive moments, provided with an exercise to practice, I felt like I had a role in the ‘team’. I felt less passive and more involved.

In my job working with children and young people, we often talk about ‘the team around the child’, when in actuality, the child should be the captain of the team rather than a separate entity in the middle! We should never do things for or to the person in our care just because it may be quicker or easier. Everything should be agreed and then achieved in partnership. A simple question such as, “Do you have any concerns or is there anything you want to know?” can quickly put the patient back in control.

2. Think about your language– Speech and Language Therapists love acronyms and all health professionals revel in a bit of jargon. Sometimes this ‘professional speak’ slips in to our conversations. Just remember that a technical term that you brush past, will be the piece of information that the patient mentally logs and googles as soon as you leave the room. I did this on multiple occasions and ended up on all kinds of forums reading horror stories about multiple tests/ailments/medications..!!

I suppose I have learned that one of our roles as a health professional should be to act as a kind of filter for google by providing accurate, concise information in a jargon free way. By doing this, the service user won’t need to reach for their phone in a panic!

3. Remember the most important reader of reports- When I was discharged from hospital, I was handed a final medical report. There were a few things mentioned that were new to me and now that I had been discharged, it was too late to discuss with anyone.

The life of a health professional is busy- on a typical day we are asked so many questions. Yet simply being an approachable, smiling face who either 1) discusses the contents of a report prior to writing it or 2) offers to discuss the report after writing it, can alleviate anxiety. Reports should never just be a paperwork exercise. We need to consider that the primary reader is the patient (or in my role, the parent of a child who I am working with). This should also inform the tone of the report and the language used (see my point above!! Googling medical acronyms is not fun!).

4. Do everything with warmth and compassion- Not everyone naturally exudes warmth….and sometimes it’s difficult to remain pleasant if someone is rude to you (unfortunately, this does occasionally happen within our roles). However, I felt most valued and listened to when a health professional dealt with me in a compassionate manner. Health professionals must remember the person who they are treating may be stressed/scared/frustrated/in pain and within that moment, they just need someone to listen and care.

From the nurse who came from my health centre to visit me in hospital, to the junior doctor who told me funny stories about his time as a patient when I was having a difficult day….These are the professionals who ‘get’ what patient care is about. Essentially, what I have learned is that the old adage is true, however clichéd it may be- treat others as you would wish to be treated. I have picked up a few tips from some of the fantastic health professionals who supported me.

If you are reading this as a health professional, you probably know all of these things. What you might not know is the difference that it makes. You could be the most technically competent doctor /physio/SLT/nurse but what a person in your care will remember most is how you made them feel.
I’m hoping that I can switch back from patient to health professional again soon; and when I do, I plan to approach my more familiar role with fresh eyes.

AAC and Social Communication- Part 2. Learn to Turn

Have you ever had a one-sided conversation?

You know the type- one of those awkward interactions in which you can end up in one of two roles; 1. The person who is being talked at or 2. The person who ends up doing most of the talking due to little response from the communication partner. Both roles are uncomfortable and don’t make for a particularly good conversation!

I like to think of a conversation like throwing a ball- one person throws something out (“Hi”), the other person catches it and responds by returning the ball (“How are you?”). The more passes of the ball, the better the game! In other words, the more communication exchanges, the better the conversation!

Children who use alternative forms of communication (AAC) such as voice output communication aids or communication books can find the idea of taking turns within conversation challenging for a number of reasons. These are some of the most common problems that I see:

1. Formulating a message takes longer so by the time the child using AAC has done this, the conversation may have moved on to a different topic,
2. Because formulating a message does take longer, the child might focus on forming their message rather than listening to what the other person is saying,
3. The child struggles to maintain a conversation because it is time-consuming and effortful.

So how do we address the all important social skill of turn-taking when a child using AAC has these extra challenges to face? I’m trying to make this series of blog posts as practical as possible, so let’s discuss a few ideas!

* Scaffolding

‘Scaffolding’ basically means providing a safe structure for a child to develop new skills, by demonstrating and prompting when necessary. It’s providing a ‘helping hand’ until the child can do it by themselves.

Some children who use AAC are unsure of how to continue a conversation- they may struggle to ask questions, make comments or ‘chip in’ with their own stories. You may initially need to scaffold this, modelling how to ask relevant questions or perhaps prompting the child to make a comment. Think about how you provide these prompts- it may initially be indirect (e.g. “I wonder has anyone else seen the new Fantastic Beasts film?”) moving towards a direct prompt if needed (“You can ask a question about the film using your question page”).

It’s important to practice these skills in everyday, natural situations. Scaffolds can gradually be phased out as the child begins to independently further a conversation. This quote from Vygotsky sums up the process of scaffolding quite nicely- “What a child can do with assistance today, she will be able to do by herself tomorrow”.

* Pause!

Never underestimate the power of ‘the pause’! Conversations can be so fast-paced that we need to consider our own communication style when chatting with those who use AAC. By simply slowing things down and pausing, we leave space for the child who uses AAC to enter the conversation. This also demonstrates that we are interested in their ideas and opinions too!

* Fringe Vocabulary

In most of my blog posts, I’ve highlighted the importance of ‘core vocabulary’- the words that we use again and again in multiple settings. However, much of our everyday conversation also includes what we call ‘fringe vocabulary’- specific topic based words such as activities, people, food, animals, etc. If core vocabulary is the bread for a sandwich, fringe vocabulary is the filling!

It’s important that these words are quick and easy to access during conversations so that the child can jump in when they need to. We need to think of how/where to store them in a communication book/device. For example, I made a ‘Hot Gossip’ page for a teenage girl who I work with so that she has quick access to words and phrases that she uses frequently when interacting with her peers. Having a ‘Quick Chat’ page or a page related to a child’s interests can be both a motivational and quick way to find ways to further a conversation.

* Teaching peers to be good communication partners

A child who uses AAC has lots to learn and many skills to constantly think about…but equally, those around them need to learn how to be good communication partners! Teaching and modelling to the child’s peers ways which they can include their friend in conversations is vital. It might be encouraging them to stop and ask their friend a question such as “What do you think?” or perhaps slowing down the pace of conversation so that topics don’t change rapidly… Practicing these skills together can support both the person using AAC and their friends.

* Start small!

It can be challenging for a child who uses AAC to develop their conversational skills in a large group such as a busy classroom or a chatty friendship group. You might want to start by working on these skills with one peer- perhaps a friend who the child has a common interest with. You can monitor how many communication exchanges occur during these interactions. It might initially be just one exchange e.g Friend: “I went to the cinema last night”, Child using AAC: “That’s cool”. As the exchanges increase, the child may become more confident to use these skills with a gradually increasing circle of friends. Starting with small, successful interactions can be encouraging, increasing the child’s confidence and skills in a safe, supportive environment.

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It’s worth remembering that many children (and also many adults…!) find turn-taking challenging! There may be times that the child doesn’t want to enter into a conversation. There may also be times when they dominate the conversation! Both of these options are fine and perfectly normal. It’s just a matter of equipping the child with the skills and the confidence to enjoy having conversations with those around them. After all, isn’t that why we meet a friend for coffee or phone someone for a chat when we’re feeling low? A good conversation is one of the best feelings! Let’s ensure our children who use AAC get to experience this too!

AAC and Social Communication- Part 1. “Hello, it’s me”….

If you work in a school environment, you’d probably find it impossible to put a number on how many times you say ‘hello’ in a day.

It might not be a formal ‘hello’ for everybody you greet but perhaps a “Hiya”, “How are things?”, “Morning!”, insert favourite colloquialism here…..

Initiating communication may appear to be one of our most basic social skills. Yet for children and young people who use alternative forms of communication (AAC), it’s not always so easy.

There are 3 distinct styles of initiating communication that I often see when working with children who use AAC:

1. Conversation Starters– children who will independently vocalize/sign/use their communication book or device to gain attention…These children have got it nailed!
2. Conversation Waiters– these are the children who rarely initiate communication but will generally respond when someone else starts the conversation,
3. Conversation Launchers– the children who will launch into a conversation before they have even got your attention. This may be by using their communication aid to say a random word or phrase!

Let’s face it; it’s not just children who use AAC who experience these problems- I have been known to be a ‘conversation launcher’ myself at times! I think what makes it more difficult for someone using AAC is that words are particularly precious- Most people who use AAC want to get their point across in the quickest way possible. For some of the children who I work with, this means bypassing the beginning of a conversation, while for others it can all seem too effortful.

Why does a conversation need a starting point? Well, without one, there is often an immediate breakdown in communication. The child may want to say something but their communication partner may be looking away or engaged in something else. This can lead to frustration or confusion. As for Conversation Waiters, they may become passive; never actively requesting, commenting or asking questions. Relying on prompts can really restrict a child’s ability to communicate freely.

So I thought we would start our series on ‘AAC and Social Communication’ with 3 tips on how we can work on supporting children to initiate communication. I’ve considered Conversation Waiters and Conversation Launchers separately under each heading as both groups need different types of support.

So let’s get started…!

1. Work on quick and easy ways to gain attention– Gaining attention is an important skill. Lots of the children who I work with develop their own non-verbal way of doing this- one young boy knocks on the tray of his wheelchair, another girl vocalizes, while another young man signs ‘book’ to indicate that he wants to use his communication book…

a) Conversation Waiters: Some children need support to hone a non-verbal method into an effective way of initiating communication. Speech Therapists sometimes use a sneaky but totally worth-it approach that we call ‘sabotage’! For example, I might place an exciting wind-up toy nearby and just leave it there. When the child vocalises or uses a body movement, I reinforce this as their attempt to initiate communication by saying, “Oh you want to have a look?!” The child begins to attach the power of gaining attention to that movement or vocalisation.

b) Conversation Launchers: This group of children know what they want to say and they want to say it quickly! To support them to do this, I often work with them to come up with a pre-stored message to initiate communication. This is usually something such as “I have something to say” or “Give me a minute”. This lets the child 1) start the conversation and 2) gives them time to formulate what they want to say next. For children who use communication books, recording a message on a switch such as or “I want to chat” can also be a good way to gain attention. Alternatively I’ve seen ‘I’ve got something to say’ wristbands. The child can raise their arm with the wristband to demonstrate they want to talk.

2. Work on greetings- I run a weekly communication group with 8 children who use different forms of AAC. In the group, we always start by greeting each other. Everyone has a different way that they like to say hello- one of the boys likes to wave, while another young girl prefers a formal “Good morning!” using her communication aid. It’s important to ensure that a child using a communication aid as has access to a range of greeting words. After all, we don’t say ‘hi’ to everyone in the same way!

a) Communication Waiters- Some children will need prompts to initiate a greeting . I came across this fab prompting hierarchy recently (see below) from Positive AACtion. The idea is that we gradually phase out prompts so that the child can eventually initiate communication independently.

b) Communication Launchers: Chat with the child about how they might use different greetings for different people. You can do this through role play or better still, real life experiences. Talk about how they would greet someone new vs a friend, etc! You can model using different greeting words using their communication aid.

3. Work on how to read (and use) non-verbal cues- When a child uses AAC, it can be difficult for them to both look at their communication system and look at the person they are communicating with…and this can lead to issues. How do we know someone is ready to chat to us? We read their body language, wait for their eye contact. We also use this information to set the tone of our interaction by observing a person’s mood. It’s important to discuss with children and young people who use AAC the need to look up; to look at the person they want to chat to before starting a conversation.

It’s equally important for us as communication partners to look at the person who is communicating and not their device or communication book.

a) Communication Waiters: When a Communication Waiter makes eye-contact, this is often a sign that they want to go beyond waiting and initiate communication. It’s important for us as communication partners to pause at this point. Giving the child a bit of time and an encouraging smile might be all they need to get the ball rolling!

b) Communication Launchers: A Communication Launcher might initially need some extra prompts to look up to check that the person they want to talk to is ready to chat.  Discuss body language and emotions. Encourage the child to think about how they might start a conversation with a friend who looks upset vs a friend who looks excited.

And a few final ideas…

• If you work with a particularly enthusiastic Conversation Launcher (!), a social story can be a great way to introduce the steps to initiating communication and to remind the child in a positive way as to how they can do this.
• If you are struggling for ways to really motivate a Conversation Waiter to initiate communication with others, try a field trip! Maybe a toy shop, a cafe or a theme park might be just the catalyst the child needs to initiate communication! Provide them with the vocabulary they need (or a recorded message on a switch), model what to do and then  wait!
• Praise the child for successful attempts at initiating communication. Give them specific feedback e.g. “I like how you used your switch to get Lily’s attention”.

 

So now that we have some ideas on starting a conversation, I’m going to put pen to paper and consider part 2 of this mini-series! In part 2, we’ll consider turn-taking and topic maintenance. Feel free to tweet me if you have any thoughts or suggestions!

 

 

Communication book remix! Colourful Semantics meets Core Words.

If you have read my blog before you will know that one of my Speech Therapy guilty pleasures is making communication books! I am always experimenting with different layouts/sizes/designs.

Another speechie tool that I love is Colourful Semantics. If you haven’t heard of Colourful Semantics, a quick Google search should provide you with lots of examples and free resources! Basically, the concept breaks a sentence down into its components or ‘thematic roles’. These roles are then colour coded, supporting a child to develop their vocabulary and sentence structuring.

The colours used can vary slightly but the standard system (as specified by Alison Bryan, who developed the system) is as follows:

Who? (Person/animal or subject of sentence)- orange
What are they doing? (Verb)- yellow
What? (object)- green
Where? (Place)- blue
What like? (Describing words)- Purple
When? (Time concepts)- Brown

An example of some sentences using Colourful Semantics can be found below:

Recently, after delivering a training session on Colourful Semantics at a mainstream primary school, a Teaching Assistant planted a new idea in my head…using Colourful Semantics in a Communication Book format!

I had been working with a young boy with verbal dyspraxia and had discussed how he needed an alternative form of communication to supplement his speech. His Teaching Assistant had started using Colourful Semantics with him and as he was so familiar with the format it made sense to base his communication book on this foundation.

I put my thinking cap on and decided that in order for this system to work it would need to have 3 main features:

1. Access to core words- We know that the most commonly used words in the English language are not nouns like ball, cat, car, etc. Words that we use again and again in multiple contexts such as ‘more’, ‘not’, ‘finished’, ‘want’, ‘different’, etc are the super important words! Lots of studies have provided Speech and Language Therapists with a starting point regarding the core words that ‘typically’ developing children use most frequently. Here is a handy list of these very important words, based on a number of research studies: https://aaclanguagelab.com/files/100highfrequencycorewords2.pdf

Every communication book should ensure that the child has access to these kind of words. In the Colourful  Semantics communication book, I stuck the core words to the inside
cover so that they were a) easy to find and b) always accessible (see picture below!)

2. A simple navigation system based on Colourful Semantics- The layout of the communication book organises vocabulary using the Colourful Semantics system. Typically a category based communication book would have a people page, a place page, etc. This book extends on that idea by having these elements arranged in a logical sequence to support sentence construction. The child can navigate through the book, gradually extending on their sentence, flipping back to use core words as and when they need to.

I added sub-categories to many of the pages e.g. the ‘what like’ section had sub-categories related to feelings, words used to describe objects and words to describe people.

3. Personalisation– As with any communication book, we need to ensure that it is created with the individual in mind. This means that we consider their strengths, their needs, their likes, dislikes, etc.

The child who I designed the book for had a preference for visual learning, limited literacy skills, difficulties with attention and listening and generally good fine motor skills in that he could point and flip pages.

Bearing all of this in mind, I limited the core vocabulary to 20 words to begin with. As he becomes more confident with these words, I plan to increase this over time, keeping the words that he is familiar with in the same position to support motor memory.

I made the book bright and colourful and cut out tabs to make it easier for him to flip through the book to find the words that he needs.

Finally, I got him to design a front cover so that he felt a sense of ‘ownership’ of the book. He drew a picture of himself and he and his Teaching Assistant typed out a few sentences about what the book was and how he would use it.

As you can see from my photographs, the colour system varies slightly from standard Colourful Semantics! Why?! Well, the school were already using a slight variation of colours- it was important to stick with what they knew as this was what the child was already familiar with.

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So, who would this type of communication book be useful for?! Well if you want to try it out, here are a few groups of children that it might be suitable for:

1. Children who struggle with sentence construction– Children who use alternative forms of communication often get stuck at using single words. Learning to combine words is tricky! Colourful Semantics aims to support children to work towards constructing sentences of increasing length by adding more content. Each element is introduced gradually but initially the focus would be on constructing a sentence with a subject (the orange ‘who’ element) + a verb (the yellow ‘what doing’ element) e.g. ‘I like’, ‘You go’, ‘Mummy play’, ‘Elsa sing’, etc. As the communication partner, you would continue to model using core words and expanding on the child’s message.
2. Children who struggle to answer questions– The colour coding element helps children to link a colour with a question e.g if asked a ‘who’ question, a child would know the answer would be located on their orange page.
I’ve also used this idea to support a young man who uses a communication app on an iPad. I simply colour coded the page buttons so that he could find how to respond to questions more quickly.
3. Children who are already familiar with the system– Colourful Semantics is used quite widely across schools in the UK. When supporting a child who already uses this approach but needs a more formal communication system to supplement their speech, this is a good starting point! The young boy I made the book for quickly grasped the idea as he was already confidently using Colourful Semantics.

 

This is just an example of a wide variety of communication books that can be used to support children to communicate. There are many alternative ideas but I like to have a bank of resources so that I can ensure that the communication system used matches the needs of the child! If you want to know more about other types of communication books, have a nosey at this blog post:
https://agrainofsalt1.wordpress.com/2017/07/20/laminators-at-the-ready-making-an-effective-communication-book/

The great thing about combining core words and Colourful Semantics is that both approaches have a strong evidence base. This makes me curious as to whether or not using these ideas together with children who require alternative means of communication will increase the ability to create novel sentence structures…Hopefully this is something that I can delve deeper into examining in the future!

 

Communication aids and Sat Navs…How to teach navigation skills

The brain is often compared to a filing cabinet. As we know, the key function of a filing cabinet is to organise information in a way that makes it easy to find.

As someone who isn’t known for their organisational skills, this has always secretly worried me- I have visions of my brain as a mass of scattered, loose pages…!

Thankfully, our brains are generally quite good at sorting information in a tidy fashion that doesn’t involve too much spring-cleaning! In fact, fMRI images have shown that our brains have a kind of ‘vocabulary map’ in which similar words are clustered together- there appear to be areas devoted to logical categories such as animals, transport, verbs, etc.

Children who use communication books or speech generating devices experience using this vocabulary map in a more physical sense. While we may mentally rummage through our filing cabinet to search for a word, someone using AAC (Augmentative and Alternative Communication) must physically flip through pages or screens to locate specific words.

If you work with children who use AAC, you will know how important core vocabulary is. Most communication systems will display core words on the home page or will provide constant access to them. These words are the building blocks to any sentence.

However, to complete a sentence, a child will often have to delve deeper into their communication system to find words from specific categories…..And I’m not just talking about noun based categories (e.g. toys, food, clothes) but also pragmatic categories (e.g. greetings, questions, comments), verbs, adjectives, etc.

Today, I’m going to share a few ideas as to how we can support navigation, specifically thinking about how the words are stored within the child’s device or book.

1. Model, model, model!

This is always rule number 1!! If you want a child to be able to locate vocabulary within their communication aid, the main way they will learn to do this is by seeing someone else use their device or book.

We must verbally talk the child through the process e.g. “We’re talking about your aunt. I’m going to go to your people page. Now I’m going to go to your family page”. By verbally labelling each page, the child begins to understand the logic behind the process.

2. Set navigation targets

As much as we need to model using the child’s entire communication system, we also need to consider SMART targets when it comes to navigation. This means that we may hone in on specific pages that the child will access independently
e.g. “X will independently access his question page 2/3 times when verbally prompted during a group  activity”.

When setting a navigation target, I try to consider it from a functional perspective i.e. what pages does the child need to access most frequently to communicate functionally?

For other children, navigation targets may be more achievable if they are based around accessing the pages that motivate them most. For example, a young boy I work with can easily locate his food page but finds it more difficult to access his verb page; so we’ve made accessing his verb page more motivational by playing games like ‘Simon Says’ or by using it during activities such as playing with a ball. He loves directing me to ‘throw’, ‘roll’ or ‘kick’ the ball to him…possibly because my hand-eye coordination is terrible and this makes him giggle!

Once a child has mastered navigating to a few key pages, we can begin to target new pages or work on moving between pages to formulate a sentence.

3. Consider cueing

When a child is learning to navigate to new pages, a ‘cueing system’ can be a gradual way to  decrease direct support. We can specify the type of cue that we will use in the child’s targets.

My hierarchy of cues generally goes something like this:
1. Direct Model- Just as I mentioned above…we take the child to the page but talk them through each step.
2. Direct Verbal Prompt + Physical Prompt- We verbally label the page that the child needs to find and guide them to the general area by pointing e.g “We’re talking about pets. You can use your animal page”.
3. Direct Verbal Prompt- As above but removing the physical support.
4. Indirect Verbal Prompt– This involves providing a bit of a ‘clue’ but not specifically naming the page e.g. “I wonder what page we might need to use at the cafe?”

As we gradually withdraw prompts, we need to make sure we give the child plenty of time to find the page that they want before we jump in!

4. Category games

One of the games the kids I work with enjoy the most involves a bag and a selection of symbols…it doesn’t get easier than that!

I place the symbols in the bag and then each child takes it in turn to withdraw one. They then have to find the symbol within their device or communication book. Again, I can use the cues listed above to support them as and when required.

Another vocabulary game that works well involves giving the children a series of clues so that they can guess and then find the word that you are talking about e.g. “I’m thinking about something that’s in the kitchen. It’s something cold. You keep yoghurts and milk inside it”, etc.

The element of competition can also certainly motivate some of the children! But the main aim is that all of the children involved in the game succeed in locating vocabulary within their individual communication system.

5. Teach how to ask for ‘help’!

This is sooo important! There will always be the occasional word that will be very difficult to find. Let’s face it; we’ve all been there- you’re modelling a sentence using a child’s device and then you can’t find the word you need!

This is why the word ‘help’ is so important! Teaching the children who we work with to say ‘help’ or ‘oops’ if they access the wrong page, can help to repair potential communication breakdowns!

 

Navigating through a communication system is initially a bit like travelling to somewhere new- the first time you go there, you might get lost or it may take you a long time…But the more times you visit that place, the easier it is to find. Eventually, it becomes automatic. Let’s give our children using AAC plenty of opportunities to navigate through their communication systems. We can initially act as their Sat Nav until they no longer need our directions!

 

 

 

AAC and Assessment- Free tools and trials!

As a travelling Speech and Language Therapist, I find that the size of my handbag is ever increasing due to the sheer amount of resources that I carry from place to place. Toys, stickers, games, therapy materials and a full battery of comprehensive assessments….I can just about lift the bag!

When working with my AAC caseload, I find my bag is somewhat lighter. I considered this recently and came to the conclusion that this is due to the lack of formal, standardised assessments for this population….And yet, assessment is so important when it comes to working with children using AAC. It helps us to set targets, monitor progress and highlight those areas that a child really requires extra support within.

A few years ago, I made my own informal assessment screening tool. It’s not that impressive- it’s a word document with tick boxes that requires you to have a bank of core symbols, communication boards, switches and motivators to hand!

But more recently, a number of new AAC assessment tools have been developed…And being a Geek SLT, I am loving trying them out! So I thought I’d list some of the tools I’ve been experimenting with and provide a brief low-down for teachers and SLTs who are keen to expand on their AAC assessment range!

The Dynamic AAC Goals Grid

This is a pretty exciting resource that I am currently a little obsessed with. Created by Tobii Dynavox it can be downloaded for the iPad alongside their fabulous communication app ‘Snap + Core First’. The sister app is called Pathways and it’s within this app that you find the Goals Grid.

One of the things that I love most about the Goals Grid is that it considers Janice Light’s well established research within the field of AAC. She discusses the 4 key areas of communication competency required to be a successful AAC user: linguistic competence, operational competence, social competence and strategic competence.

The Goals Grid takes these 4 areas and gives you a checklist for each. The iPad app then provides you with a handy percentage so that you can quickly see the ‘level’ that your child is functioning within- emergent, emergent transitional, context dependent, transitional independent and independent.

You can then quickly see the areas that the child needs to focus on to progress to the next level. The clever thing about the app is that there is also a ‘Build Skills’ section which provides you with top hints, handouts and in-depth information on targeting specific core words! Amazing!

If, like me, you quite like a paper version of your assessment, here’s the link: https://www.mydynavox.com/Content/resources/slp-app/Goals-Goals-Goals/the-dynamic-aac-goals-grid-2-dagg-2.pdf
Handy to print out, fill in and place in a student’s file to frequently review progress!

The Communication Matrix

This is a fabulous free (love that word!) online resource. All you need to do is create an account here: https://communicationmatrix.org/Matrix/MatrixChart/Mobile/270538
You can then create profiles for multiple students.

The Matrix asks you a series of questions about skills that the child you are working with may be displaying. One of the nice features is that it also shows you a video clip of the skill in question e.g. examples of how a child might attract attention/protest/request more of something, etc. This includes non-verbal responses that may be used pre-AAC such as body movements or vocalisations.

When you have completed the question section, you are then presented with a colour-coded grid, clearly demonstrating skills that are consolidated, emerging or not yet present.

I find that this is a useful tool for starting out with a child on their AAC journey as it starts with the basics and considers simple factors such as non-verbal cues and vocalisations. It can give you an indication of the first steps for a child who doesn’t currently have a formal communication system. You can also save and print the Grid and return to it as an when you need to update information.

The Pragmatics Profile for People who use AAC
If you are an SLT you are probably aware of the standard Pragmatics Profile and have spent many an afternoon completing it with parents and teachers!

This is a clever adaptation of the original profile but specifically for AAC users. You can find it here, on the ACE Centre website: https://acecentre.org.uk/resources/pragmatics-profile-people-use-aac/ Again, it’s FREE!!

This is a nice way to gather information and evidence about a child’s communication skills, involving the people who know them best- family and/or education staff. It provides really comprehensive information that you can then consider when setting goals.

CARLA (Computer based accessible receptive language assessment)
One of the reasons why typical standardised assessments can be tricky  to use with  some children who use AAC is that they require direct access e.g pointing to a picture or manipulating objects in Derbyshire Language style assessments. Yes, you can adapt a BPVS with something such as an E-TRAN frame but it’s highly time-consuming!

The unique feature of the CARLA software is that it has multiple access methods- eye-gaze, auditory scanning, switching and finger-pointing!! How clever is that?! You can download a free trial here: https://www.techcess.co.uk/carla/

The assessment looks at understanding of basic vocabulary from nouns and concepts to verbs. It then examines understanding of information carrying words- Can the child listen for 2 or 3 key words in an instruction? Clear, colour photographs are used to make the assessment visually accessible. Results are then transferred into a Microsoft Excel document.

So at last we have a tool that can provide quantitative data for a child who needs an alternative access method….And we can then pinpoint areas of understanding that the child may require support with before working on that area expressively through AAC.

For example, I recently used the CARLA assessment with a young girl who I work with who uses an eye-gaze communication aid. She seems to have got ‘stuck’ on single words and carrier phrases and I wanted to get to the bottom of why this may be. It soon became clear that her understanding of verbs was inconsistent. So by targeting her understanding of verbs we can then begin to develop her use of them, building towards 2 word phrases such as person + verb.

 

You may have noticed a theme in the assessments that I have listed… They are all free to use or trial! That’s always a bonus!

It’s definitely worth considering how each assessment can further examine different areas of an AAC user’s communication- from the beginnings of intentional communication, to receptive language, functional communication and operational use of an AAC device…There is so much to consider! Setting goals for children who use AAC just got easier!

 

Tricks for transitions- Reducing anxiety in daily routines

 

If you were asked to brainstorm all the words that you associate with ‘change’, what kind of words would come to mind? Adjectives such as ‘difficult’? Emotions such as ‘anxious’?

The truth is, most of us aren’t that keen on change. It takes us out of our comfort zone and places us somewhere unfamiliar….And while change is a normal and necessary part of life, children with speech and language difficulties or Autism can find it pretty terrifying.

I don’t just mean big changes like moving house, changing teachers or going somewhere new- everyday transitions can be equally baffling and scary.

How can we make it easier? How can we maintain some consistency in a fast-paced, ever changing school day?

1. Use simple, familiar language

First of all, it’s important to signal that a change is going to occur. But let’s really consider our language when we do this…

e.g “Ok it’s nearly time to tidy up but before we do that let’s wash our hands and then after that we’ll get ready for PE…”, etc, etc!

There’s a lot to process in this instruction- sequencing words such as ‘before’ and’ after’, vague time concepts such as ‘nearly’… For a child with difficulties understanding language, this could be an overload of information, causing them to feel more anxious!

However, if at every transition you used a similar phrase such as “Art is finished. Now it’s lunch time”, this is much more straight forward. The child knows what is happening and when it’s happening. You can accompany this with a visual such as a sign(e.g. the Makaton sign for ‘finished’)/symbols or photographs to visually reinforce understanding.

2. Visual timetables/timelines

I’m sure most of you reading this article have used visual timetables before and don’t need me to greatly elaborate on the process. But it’s important to consider that one size does not fit all...! We need to consider the needs of the child before we start printing and laminating copious amounts of symbols from twinkl/Boardmaker/Insert other software here….!

We’ve got to consider these things:

a) What representation of an activity will the child understand best- an object, a photograph, symbols..?
For some children, symbols or line drawings are too abstract. Maybe we need to start with objects of reference e.g. a fork to represent lunch, a book to represent carpet time, etc.
Other children respond well to photographs of themselves partaking in the routine e.g a photo of them sat on the carpet to represent registration.

B) How many transitions we visually display- Yes, it’s easier to lay the whole day out first thing in the morning, placing all the symbols on the timeline. But for some children this is a visual overload that then loses meaning.

For some children a ‘Now and Next’ style transition board is enough. Other children might be able to cope with 3 visuals- ‘First, next, then’. Some will be fine with the whole day laid out on the timeline.

Don’t forget- make the timeline portable! There’s nothing sadder than seeing a beautifully made visual that’s stuck to the wall and never used!

3. Transition songs

Ah YouTube…It has a child-friendly song for just about everything! A quick search and you can soon find plenty of songs that can be used to signal transitions…From good morning songs, tidy up tunes, lunch time beats to home time hits! It’s a fun and simple way to support the structure of the day.

4. Traffic light system

Possibly one of the simplest visual aids to make, requiring only 3 coloured circles- green, amber and red. These can easily be attached to a lanyard so that they are always to hand!

The idea is that each colour represents a different stage of the activity. You show the child the coloured circles to make them aware of what stage of the activity they are in.

Green means go- the activity is starting.

Amber means getting ready to finish– the child is made aware that the activity is ending soon. You don’t have to put a specific time on this (it can be difficult to quantify when an activity will end!) but make sure it is no longer than 5 minutes.

Red means stop- the activity is finished.

A very simple but effective visual!

5. Social stories

You may have noticed that certain parts of the day seem to cause more anxiety than others…Maybe it’s P.E; moving rooms might cause confusion. Maybe it’s lunch time; the child might struggle to socially interact with their peers in the playground.

Once we have identified aspects of the school day that may cause issues for the child, we can write them a tailor-made
social story. The story should explain the situation to the child, describe what might happen and how they can respond. Use photographs, symbols or the child’s own drawings to personalise the story even more!

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Small transitions occur frequently in our daily lives. As adults, we are accostumed to them and we take them in our stride. In fact, we hardly even realise they are occcuring at times- How often do we go into auto-pilot as we move between places or activities?!

Let’s take a minute in the busy school day to consider how we can support our students to begin to experience these seamless transitions. Choose one of the transition tricks above to start with and then persevere! Nothing works over-night; using an approach consistently will help the child to understand the purpose of the transition trick and to link it with changes in their daily routine.

‘Curiouser and Curiouser’… The importance of asking questions

“Judge a man by his questions, not by his answers”- Voltaire.

My curiosity led me to Google this morning. I typed into the search box:
“How many questions does the average adult ask per day?”

Unfortunately, my Google search really left me with more questions than answers (which often seems to be the case when I find myself thirty minutes later, trawling through Google Scholar/The Guardian/You Tube, with questions only slightly related to the original…!)

Anyway, I did find out a few interesting pieces of information:

1. A study commissioned by Littlewoods in 2013 found that the average British mother is asked almost 300 questions a day,
2. The amount of questions we ask per day decreases with age and varies depending on gender- 4 year old girls ask approximately 390 questions per day while 9 year old boys ask around 144.

So, let’s say that the average child asks a question every 5 minutes…What about children with speech, language or communication needs (SLCN)? Do they ask more/less than their peers? Do they ask a variety of questions? Do they ask the questions that they NEED to ask? I’m sure there is a research study in these questions alone!

But more importantly- do we make asking questions an important part of language learning?

We often prioritise requesting, commenting, answering questions…But as it turns out, asking questions is a massive part of a ‘typically’ developing child’s everyday language!

And questions have so many functions… we ask questions to start conversations, to gain information, to connect with people, to discover new things, to reduce anxiety/increase clarity…

It’s recently come to my attention that the children who I work with who use augmentative and alternative communication (AAC) such as communication books and voice output devices, ask fewer questions than their verbal peers.

I think one of the reasons for this might be that we target so many other functions of language that we deem to be motivational; questions seem to be more difficult to approach.

But actually, isn’t there something quite motivational about being nosey/inquisitive…?!

For example, if I put a massive box in the middle of the table, with ribbons and bows around it and didn’t mention it; what child wouldn’t want to ask, “What’s in the box?!” or “Can I see?!”

Here are a few ‘thinking points’ to develop inquisitive minds within our AAC users:

1. Think about question structures

Speech and Language Therapists often talk about ‘Wh questions’- These refer to question starters such as who, what, where, when, why and how (‘How’ breaks the ‘Wh’ rule…!). It’s important to have these words as part of a core vocabulary- to introduce the symbols and model how to use them and combine them with other symbols to form questions.

I like to do this during turn-taking games. In fact, I’ve made a massive A2 sized ‘Question board’ for both myself and my children using AAC to use for asking questions during games e.g
“Whose turn?”
“Where’s the dice?”
“What’s next?”
“Can you help?”

And depending on the game, you can build in lots more questions- ‘Guess Who?’ is the ultimate question asking game!!

2. Think about the questions that kids ask kids!

Listening to children’s conversations I’ve noticed that these simple question structures crop up again and again:

1. Do you have….? (a dog/an x-box/ a barbie/ a football, etc, etc…!)
2. Do you like….? (Paw Patrol/ Taylor Swift/ Swimming/ Man United, etc, etc…!)

So bearing this in mind, it’s nice to practice these questions in social situations or as part of a group activity.

I’ve made some page sets related to social questions for a child who uses the Grid 3 software- A cell for “Do you like…?” jumps to some of the child’s favourite activities/music/TV…That way, the child can find out what they have in common with others.

Isn’t this how friendships form?!

3. Think about what intrigues the child!

It goes without saying, but if you are asking a question it’s because you want to know the answer! So we may need to motivate our children to want to find out some information.

The big, surprise box that I mentioned earlier is a starting point…But what else might intrigue the child?

Perhaps writing a letter to their favourite celebrity- you could spend some time discussing together which questions they could ask. Or similarly, maybe a group interview session with the Head Teacher?!

Maybe a Hide and Seek type game or a scavenger hunt- hiding a motivational object somewhere in the room.

Or perhaps, we withhold information and then pause…The power of the pause cannot be underestimated!

For example, if the class teacher was to say, “We’re going on a trip next week” and then paused, not providing further detail; that’s surely going to incite some curiosity! Everybody will want to know where they are going to….and to find out, they are going to have to ask!

 

The statistics I found on Google would suggest that children’s curiosity eventually peaks…It seems that teenagers and adults don’t feel the need to enquire so much, to ask those interesting ‘why’ questions that a 4 year old would (The Telegraph suggests one of the most common, interesting questions asked by children is: “Why is water wet?!”).

So let’s harness that period of curiosity and make it a language learning opportunity for children who use AAC! You might be asked some bizarre questions along the way, but isn’t that part of the fun?!