“Speech is the most important thing we have. It makes us a person and not a thing. No one should ever have to be a thing.”-Dorene Individual who uses AAC
Augmentative Communication-How Do Pediatric Occupational
and Physical Therapists Fit In?
Molly Shannon, OTR/L, ATP
Tammy Pereboom, PT, ATP
North Carolina Assistive Technology Program
www.ncatp.org
NCATP Overview
Federal and state funded Tech Act Program Free consumer consults if no funding source Fee based evaluations, trainings Interagency collaborations Loan Program Speech to Speech Dial 711, Overview/handout Work with all ages and all disabilities in many
western NC counties (depends upon age as to which counties, but about 12-22 counties overall)
Overview, Introductions
Molly and Tammy’s bios Course Objectives: definitions, OT/PT roles, AAC,
Assessment, Access, Mounting, Devices, Resources Agenda, Handouts Two Breaks, Restrooms Tours of AT center available in breaks, Devices available
for hands on Scott Chapman of Dynavox and Dawn Haynes from
Prentke Romich are here, thanks! Participant Introductions: name, where work, main
reason they are here today
Why Aren’t OTs and PTs Using AT or Helping with AAC? Lack of experience and/or confidence Too little time for additional training Little access to AT in particular settings No mentors Just don’t get it, no buy in yet or “ah-ha” moment or client Afraid to admit sometimes that we don’t know Lack of institutional or supervisor support Lack of resource information Fear of technology! Batteries to hard drive analogy. YOU ARE HERE! Thanks for coming!
Definitions of OT, PT and AT AOTA: OT is skilled treatment that helps individuals with
disabilities achieve independence in all facets of their lives. It gives people the “skills for living” necessary for independent and satisfying lives.
APTA: PT includes: Examining individuals with impairment, functional
limitation, and disability or other health related conditions in order to determine a diagnosis, prognosis, and intervention.
Alleviating impairment and functional limitation by designing, implementing, and modifying therapeutic interventions.
Preventing injury, impairment, functional limitation, and disability, including the promotion and maintenance of fitness, health, and quality of life in people of all ages.
Engaging in consultation, education, and research.
AT Definition from PL 100-407:
AT Device: Any item, piece of equipment or product system whether acquired commercially off-the-shelf, modified, or customized that is used to increase or improve functional capabilities of individuals with disabilities.
AT Service: Any service that directly assists an individual with a disability in the selection, acquisition, or use of an assistive technology device.
According to ASHA, augmentative and According to ASHA, augmentative and alternative communication (AAC) is an alternative communication (AAC) is an integrated group of symbols, aids, integrated group of symbols, aids, strategies, and techniques used by strategies, and techniques used by individuals to enhance communication. individuals to enhance communication.
AAC serves as part of a person’s AAC serves as part of a person’s communication system, supplementing communication system, supplementing gestural, spoken, and/or written gestural, spoken, and/or written communication abilities.communication abilities.
What is Augmentative and Alternative Communication (AAC)?
RESNA Certification for ATP
Now is only one certification for professionals and vendors
Used to be ATP and ATS We do have ATPs from wheelchair
companies in Charlotte Exam, ongoing continuing education,
training, ethics, etc. www.resna.org
What Augmentative and Alternative Communication (AAC) Does: Facilitate language development Provide a different form of
communication, enhancing the student’s present communication system
Increase independence Facilitate academic development and
classroom participation Offer opportunity for social interaction
AAC may involve: Low tech techniques, like picture schedules, Picture
Exchange Communication Systems (PECS), and communication boards or books. Students touch/point to or look at objects, picture symbols, words, or letters to communicate.
High Tech techniques/devices with voice output that provide students with a way to speak intelligibly. These approaches give the student the opportunity to use pictures, words, or letters to produce a single message,
“Please, turn on the fan.”
AAC Device Overview
Quick look at some low to high tech devices
No tech ideas: flip, boards Partner One and other less expensive one message devices:
Yes, Virginia there are more options than Big Macs!!! Tech 8 with ECU Tech 32 with levels Dynawrite Springboard Lite Dynavox V Eco 14 PASS Software for demo, nice option for training! Show Access
Hands on during breaks
A Beginning… I drew it, the letter A. There it was on the floor before me. I
looked up. I saw my mother’s face for a moment, tears on her cheeks. I had done it! It had started, the thing that was to give my mind it’s chance of expressing itself. That one letter, scrawled on the floor with a broken bit of yellow chalk gripped between my toes, was my road to a new world, my key to mental freedom.
Christy Brown, 1954 My Left Foot, movie and book
How can therapists not believe that we are a vital component of AAC delivery?
Communication is not only the essence of being human, but also a vital property of life. John A. Piece
“Molly or Tammy? Why Did You Stop Being an OT/PT?” WRONG!! We have never stopped being OTs and PTs. We are proud to be OTs and PTs!! Some in AT, not
so much! We are therapists that specialize in AT. AT professionals come from all backgrounds, but OT
and PT are logical choices. We have always done adaptive equipment and AT
is just the umbrella term for all of the equipment categories.
As do more AT, become more of a generalist and lines merge with professions.
If you want to know what it is like to be unable to speak, there is a way. Go to a party and don’t talk. Play mute. Use your hands if you wish, but don’t use paper and pencil. Paper and Pencil are not always handy for a mute person. Here is what you will find: people talking: talking behind, beside, around, over, under through, and even for you. But never with you. You are ignored until finally you feel like a piece of furniture.
Rick Creech Individual who uses AAC
Categories of AT: Today’s Focus is AAC But Access Overlaps All Areas of Course!
Computer Access Augmentative communication Activities of Daily Living Environmental Controls Seating, Mobility and Positioning
Assessment Assistance: AT assessment, $6 month for individuals, free 4 wk trial
at www.customtyping.com GREAT site. WATI free AT eval form (37 pages) and other materials
online, http://www.wati.org/content/supports/free/pdf/ASNAT4thEditionDec08.pdf 337 page guide to AT, Section 9/10 on seating and positioning. Great forms!
GPAT www.gpat.org FANTASTIC protocols, 14 page one on AAC and OT and PT “areas” are nice
SETT (Student, Environment, Task, Tools) Zabala, hard to find now, but many use. Forms similar in WATI above.
MSIPT (DeCoste 1996) Find still?
MSIPT, handout is an old form, but nice! Assessment form, hard to find anymore
Checklist for charting 3 observations with 3 different devices
M=movement S= site of control I=input method P=position of input T=targeting method
http://public.doe.k12.ga.us/DMGetDocument.aspx/AAC%20Evaluation%20Protocol.pdf?p=6CC6799F8C1371F64E4F53D91653586E66B5D054B9D6977ACF2448B2C7785534&Type=D
Suggested Team Roles: No One Person Can Wear All the Hats!
Language/Communication: SLP Programming of AAC: SLP, AT,
parent/consumer, or other with interest! OT/PT?
Curriculum Integration/Literacy: Teacher, AT/OT
Physical Access and Positioning: OT/PT, AT Linking and Computer: AT or other interested
staff, some parents/consumers Mounting: some would say PT only, but really
anybody willing to try!!!
OT/PT Role Typical Roles in AT Evaluation: Functional range of motion Strength Sensory Cognitive, depending upon team Coordination Reach Hand Strength and finger isolation or other isolated
access control Functional skill levels Posture, changes in position and environments
Assumption: Interdisciplinary Assessments
Best to have entire team’s input
Current assessments
Parent and consumer/client info vital
Copies of private or outside evaluations or reports helpful
Assessment: A Process, Not An Event
Assess to meet today’s needs, then tomorrow’s, and tomorrow’s and tomorrow’s…
Beukelman and Mirenda
Georgia Department of Education , GPAT: Principles of Assistive Technology Evaluations
•Smith (1993) points out that the Goal: Is not Which Device, Rather….
What (The child needs to be able to do)
Where (In what environment)
Why (For what specific purpose)
How (Possible ways to help the child accomplish described tasks in specific environments)
Then, which device combined with which services and which individual strategies= FEATURE MATCHING
AT Evaluation Considerations
Sensory Skills: hearing, vision acuity, perceptual/discrimination issues
Seating and Positioning: ambulatory issues vs. non-ambulatory
Individual Abilities Motor and Access, Direct Select vs. Switch vs.
Scanning Receptive and Expressive Communication
Communication Needs Language Functions Environments/Partners Tasks
Hierarchy of AT/AAC Access
KeyboardMouse TechnologyProportional JoystickSwitched Joystick4 switches3 switchesSingle switch scanning2 switchesSingle switch
Least Restrictive Access
Most Restrictive Access
Evaluation process, Direct Select? Most preferred method1. Direct Selection: Determine student’s gross and fine
motor abilities as related to accessing a system using direct selection, including Range of motion Position changes Move your object around the area in front of student, assess to
the right/left, top/bottom, midline/cross midline Have them touch, point or pick up items Fine motor control –how do they touch/point? Ability to achieve an isolated point, closed fist, hand, arm, etc. Strength and motor control 90/90/90 myth!
Access Evaluation, cont.
Delays in processing/motor recognition/initiation
Observe/measure how long takes to recognize direction, initiate motor movement and complete motor act
Ability to utilize adapted equipment for direct selection, if unable to access independently
Try handheld pointers, splints, t-bars, headpointers, etc. and repeat range and control observations
Direct Selection Access Evaluation, cont.
Determine degree of accuracy student can use to access targets of various sizes
Maximum range and number of targets student can access
Extent to which adaptations can be used to optimize accuracy, efficiency, and range of motion
Determine student’s ability to utilize alternate input devices for adapted direct selection (with AAC or computer based systems)
Mouse, Trackpad, Joystick/trackball, headpointing system
Eye Gaze vs. Head Control Access
Prentke Romich devices that are Plus have the Tracker infrared input
Can add on Head Mouse or Smart Nav to any device as access if correct cabling, USB, etc.
Magitek products nice too
Head/Mouth Based Access Demos
Head Mouse Others available Low tech options to remember is :
Mouthstick QuadJoy? Jouse for access, mouse/sip
and puff access
Eye Gaze Overview Dedicated computers or
AAC devices now Products: Eco 14
EcoPoint, EyeMax from Dynavox, Erica, Quick Glance, Tobii, LC Tech
Cost, high but less than
used to be! 4K-20 depending upon if buying AAC device or computer
Evaluations cost for true eye gaze systems
If Cannot Direct Select, Assess for Switch Access Determine student’s ability to use single switch access
(using switch toys, music, w/ SLAT or Powerlink, motivating software with switch interface –no scanning at this point)
Identify activation sites student can use to activate one or more switches
Identify possible switch types Determine student’s ability to Activate a switch on command –how quickly, how easily Release a switch on command –how quickly, how easily Reactivate a switch –how quickly, how easily Hold and maintain closure on a switch –how easily Complete the above listed areas on a variety of
activation sites and switch styles
Hierarchy of Access Sites: Can Have Multiple Sites for Access
HandsHead/voice Arms/elbowLegs/kneesFeet
Switch Access Evaluation, cont. Determine student’s ability to use two switches for
potential dual switch/step scanning –two sites easily
Determine student’s ability to release and reactivate switch to continue use of communication system
Determine student’s ability to using scanning access for communication system use live voice scanning or partnered visual scanning with single message voice output device
Assess student’s ability to watch a visual cue, process and activate the switch when it is on a designated target (stand behind student if using an infrared pointer -start with one target, move to 2 –designate target, then go to choice 2-4)
Spectrum of Switch Training and Use
Play, Exploration, Leisure Communication Movement: Cooper Car, power chairs Activities of daily living and Environmental
control (EADL) Education, Computer Pre-vocational and vocational
toys job
Top Tips for Switch Selection: Movement Issues: naturally occurring, volitional, social
and communication issues, motivation is key
Positioning and Environmental Concerns: team assessment helps, space constrictions, reflexes, mounting, different locales/times different access?
Performance Variables: Target size, Force,Timing, Accuracy, Efficiency, Durability, Safety and Fatigue
User Input: Interest and acceptance, Fun for younger users, Increases independence, Comfortable, Ease of use, Reliability, Cost issues
Professional or Family Support Pointers: Wait!, consider previous attempts, try it yourself!, ease and reliability of set-up by staff/families
1.Movement Issues
Observe naturally occurring movements Look for a volitional movement Don’t let it take away from communication
interactions Social considerations in different settings Motivating movements will often win out
2. Positioning and Environmental Concerns
Importance of prior team assessment Reflexes: ATNR, STNR Space restrictions Different access site and switches for
various settings, times of day 90/90/90 Mounting issues
4. User Input
Interest and acceptance Fun for younger users Increases independence Comfortable Ease of use Reliability Cost issues
5. Professional or Family Support Pointers
Wait, wait, wait for responses
Consider previous successful attempts
Try it yourself to see how it feels
Ease and reliability of set-up for caregivers is key
Categories of Switch Types
Pressure: push or lever Pneumatic: air sensitive such as Sip and
Puff Motion (mercury or infrared) or motoric
(pinch, grip, etc.) Photosensitive: Blink switch
More Switch Types
Physioelectric or sensitivity (muscle tension):P switch
Sound activated Remote or proximity: Cordless Big Red or
Untouchable Buddy/TASH Taction switches:attach to surface of item or
page of a book, but need Linkswitch Flexible Switches: Adaptivation, work with any
device and stick to surface
Switch Hands On Activity #1
Each small group gets a bag of goodies Within each bag there is:
a mount or some type of positioning device a switch low tech AAC, book or toy
You will put mount and switch or devices together (15 minutes) Brainstorm what kind of client could use Some bags require more problem solving than others! Extra materials on table if needed, tools, tape, Velcro, etc.
Every group will share briefly name of products and your ideas to group for show and tell. (15 minutes)
Ideas for Feature Matching with Switches: Varies with Clients! Cerebral Palsy: coordination is
key
Neuromuscular (ALS, MD, SMA): strength, ROM, fatigue
Spinal Cord Injuries: high level quads
DD/MR: bright, big, sturdy
Visual Impairments:
Pressure, rocker, wobble switches. Mounting!
Spec, light touch, blink, P switch, cup, microlite
Sip and puff, tongue, head controlled
Big Red, Bass, wobble, auditory
Texture switch, auditory feedback
Direct Selection vs. Scanning Direct Input Methods: hand, feet, pointers, mouthstick,
splints, eye gaze Direct Input Devices: keyboards and alternate keyboards,
eye gaze boards, low tech, onscreen keyboards, etc. Scanning is not direct selection and is most restrictive
access Be aware that the entire AAC device screen can be one
big switch! Nice option for many children. Linda Burkhart great resource for teaching various switch
skill progressions www.lburkhart.com/hand2sw4s.htm
Scanning: Techniques
Automatic: runs automatically number of times programmed to
Step: press to select and advance movement of cursor
Directed or Inverse: hold down switch until movement stops
Switch Use Specific to AAC Devices
System specifics see manuals, websites, reps. Thanks Scott Chapman and Dawn Haynes!!!
Scanning Options: direction, type, speed, auditory
Setting scan patterns Assessment guide in Dynavox :ROM/targeting,
Scott demo Encoding: ex:, eyegaze boards, Minspeak and
morse. Very HIGH Tech info!
Visual and/or Auditory Scanning
Visual LED issues: one light in corner or entire message
outline Bi-modal Communication field importance
Auditory Entire web sites devoted to this method Cognitive and memory load Ironically often recommended for low functioning
clients
Regarding Scanning…
It should be emphasized that saying it can be done is not the same as saying it will be easy.
Stainback and Stainback
Stephen Hawking, from a
A Brief History of Time
“For a time after the tracheostomy operation the only way I could communicate was to spell out words letter by letter, by raising my eyebrows when someone pointed to the right letter on a spelling card. It is pretty difficult to carry on a conversation like that, let alone write a scientific paper.”
Lightweight Mounting Ideas
Usually holds 5 pounds or less Typically for switches or ECU devices and
lightweight AAC devices You typically use what you have and don’t
even know the ‘real’ name of it Many therapists make their own mounting
solutions from low tech materials
Slim Armstrong, $279 www.ablenetinc.com Versatile, strong, and easy to use. Easy positioning with ball joint. Telescoping arm stretches 20.5”. Support up to 5 pounds. Clamps to flat table surface or round wheelchair
frame. Five mix and match parts to create four different
systems. No tools needed!
Universal Switch Mounting System, $219
www.ablenetinc.com Heavy-duty system, friction knob. Holds up to 5 pounds. Many positions, arm adjusts and locks by turn of
lever. Ideal for assessment or computer stations. Includes large triangular mount for larger
switches. Ablenet: $219
TASH Mounting Arm
www.ablenetinc.com $252 Any TASH can attach
Also… Cling Arm $120
Mini Arm from RJ Cooper
www.rjcooper.com $99 The Mini-Arm is a variation on
the Articulating Arm. Included is the great Super-Clamp so the Mini-Arm can be mounted to just about anything. The Mini-Arm ranges from 4-11". It comes with a 1" (for our Compact Switch) and 2.5" (for our Buddy Button) round plastic disk at the end, with Velcro, to mount switch.
Articulating Arm by RJ Cooper
$119 Three knobs to tighten,
versus one, and is not quite as strong as the Magic Arm. But it is less expensive, stronger, and much easier to use than some.
Magic Arm from RJ Cooper
$219 The base clamp attaches
securely to just about anything: wheelchair tubing, tables, the CooperCar rollbar, you name it! The dial at the elbow tightens all three joints: the one at the base, the elbow, and the switch end. And when it's tight, it REALLY holds everything in perfect place.
Mighty Mount, Ablenet/TASH, $170
Attaches to any surface: table, chair, wheelchair, bed.
Easy to position. Adjustable arm lengths, arm angle, and switch
angle (length 16”-24”) Best suited for Tash switches
Adapt-A-Tray
$685, plus http://
www.customsolutions.us/adaptatray/index.htm
The AdaptaTray is a new and unique upper body positioning system to assist individuals with physical disabilities to access equipment in their work and learning environment.
Dedicated AAC Mounts
So many available, we are showing representative or more popular ones
Some companies only recommend one or two vendors they prefer
Pricing is confusing This is a tricky area. Ask for help from vendors
and dealers Warranty and customer support is important
Folding mount/ Rigid Mount
Used for voice output communication aids, laptop computers, trays and communication boards.
Vertical and horizontal tube joined at right angle. Clamps onto wheelchair by Frame Clamp Assembly. Folding mount folds completely down beside
wheelchair. It may stick out from chair and hit wall when folded. Can be mounted on left or right of chair.
Rigid mount has no moving parts. It should be detached when mount is swung around beside wheelchair.
Folding and Rigid Mounts
Rigid mountFolding mount
Rear folding mount
Profiler Mount from CJT, $740 Is a new innovative design that makes
mounting to wheelchairs, walkers, hospital beds, stroller's and tables a breeze.
Can mount to square , oblong, and round tubing. You can use either vertical or horizontal tubing.
Can even be mounted to the inside of some chairs and brought out from the side and up.
It's lightweight and easy to adjust. Can move to the side with the single lift of
a lever. Can be used with most of the
communications devices on the market. Users have a choice of using any of the augmentative communication company's quick release, or C.J.T.'s device plate or C.J.T.'s new quick release system.
Benefits of Profiler
Easy to use. Installs in minutes not hours. Variety of angles and heights can be achieved within
seconds. Can change to clients new chair with minimum to no charge. Can hold up to 15 lbs. Nice looking. Light weight. Can swing away to the side. Can mount on the left or right side. Cost:
Profiler Lite from CJT The ProLite mounting system is specifically designed to
work with small and lightweight devices. Is simple to use and offers a variety of options. It's low profile makes it appealing to an individual while its
flexibility and durability accommodate real needs. Ordering the ProLite is simple. You choose one product code, giving you all the parts
you need to mount the ProLite to either the left or right side.
You can mount the ProLite to the base of the chair, the back, the arm, just find a small space and you can mount the system in minutes.
Profiler Lite, $265
Easy to assemble and disassemble. Mounts to both left and right side. Fully adjustable-Base turns 360 degrees. Mounts to square or round tubing. Lightweight. Works with most light weight devices. Max load 5lbs. Mounts to wheelchairs, hospital beds, walkers, IV poles and more. Come with device quick release. Mounts to vertical or horizontal tubing. Choice of length 9" to 16" or 16" to 21". Durable.
Freedom Table Mount, $475
Freestanding. Hands free support on any surface. Change angles, height, and rotate 360°. Locks into position. Quick release lever allows quick positioning for
use. Can be used with all AAC devices and most
notebook computers.
DAESSY Mounting System from DAEDALUS
http://www.daessy.com/dms/indexm.html
The DAESSY Mounting System is a component based system that allows for customization and limitless configurations to meet mounting needs.
Selecting a Mount handout: http://www.daessy.com/PDF/select.pdf
What are the Names of the Parts of my Daessy Wheelchair Mount? http://support.prentrom.com/article.php?id=325
The picture is the Daessy Wheelchair Folding Mount shown with the Standard PRC Quick Release Mount and 7/8" round frame clamp. Frame clamps come in different hole shapes and sizes, so your clamp may look a bit different.
Daessy Wheelchair Mount, cont. The Daessy bar comes in 2 different lengths called
offsets, a 6"offset or a 12" offset. A 12" offset adds inches to the Vertical Tube at both the bend section and to the length where the collar is attached. The shorter the offset, the closer the device will be to the person using it.
Mount ‘n Mover www.broadenedhorizons.com The Mount'n Mover system lets individuals choose
where and when their mount is positioned with devices, trays or laptops can be at-the-ready, not in-the-way.
2 easy to use knobs, one handed operation, customizable, holds up to 15 lbs. Cost from $800-1200ish
Mounting Worksheets… Dynavox: Handout “Mounting Worksheet”
http://dynavoxsys.custhelp.com/app/answers/detail/a_id/2218/kw/mounting/r_id/158 and additional questions for “Wheelchair Mount Ordering Basics” http://dynavoxsys.custhelp.com/app/answers/detail/a_id/4187/related/1/kw/mounting/r_id/158
DAESSY: 7 pages long http://www.daessy.com/PDF/select.pdf
Installation of DAESSY http://support.prentrom.com/article.php?id=330
How do I Determine the Proper Bar Length for my Mounting Kit? http://support.prentrom.com/article.php?id=799
Challenges in AAC Mounting: Michelle Lange, http://www.medrehabnetwork.com/art-
adee.cfm?artID=9042 Unusual tubing sizes Stroller frames are simply not strong
enough. Ultra lightweight manual wheelchairs Swing away mounts Transfers
More Challenges in AAC Mounts
Wheelchair and mounting companies are not always in sync with products, devices, and support
Tilt and/or recline systems Never mount these systems to moveable
parts.
More Challenges…
Overall width of the wheelchair and device.
Visual field and social issues. Multiple bases and environments. Pricing information, modular issues.
Frustrating to not know how much is going to cost!
Bottom Line with Mounting…
Someone has to put this mount on the chair! Believe me, your average caregiver just isn’t going to do it.
Who can or will help? Wheelchair vendors, AAC vendors, interested
therapists, Rehab Engineers, dads If you have to have an engineer mount the
device, then is that the mount you really want for that client?
10 things I wish my teacher knew about AAC (insert AT or therapist, parents, etc) ASHA and Callier Center, Dallas
1. I wish my teacher would joke with me. 2. I wish my teacher would learn how to work my communication device. 3. I wish my teacher would stop shouting at me like I can’t hear. 4. I wish my teacher would remember that I don’t always spell very well. 5. I wish my teacher wouldn’t have a heart attack when my device doesn’t work. 6. I wish my teacher would have more patience with me. 7. I wish my teacher wouldn’t hit my machine when it doesn’t work-that’s my mouth she’s hitting! 8. I wish my teacher would call on me for Share Day. 9. I wish my teacher would give me enough time to say what I’m thinking. 10. I wish I could walk and talk like my sister and brother.
Resources
Various AT, great site from OT Bridget http://www.customtyping.com/tutorials/at/switches/assessment.htm and http://www.customtyping.com/tutorials/at/switches/movement.htm Joint movement switch tutorial and same gal at http://www.customsolutions.us/
Great for AAC info! Tons! http://aac.unl.edu/yaack/toc.html
Dawn Haynes from Assistive Technology Works
Prentke Romich Company rep 540-337-4640 [email protected] www.prentrom.com Great online tech support and telephone
too from PRC
Scott Chapman, Dynavox
Lives in South Charlotte! Phone: 800-344-1778 ext.7937 [email protected] www.dynavoxtech.com Great online
support and tech support as well Training videos within some products
which is great.