Problem-Based Learning in Fluency and Stuttering

Unless otherwise noted, the publisher, which is the American Speech-LanguageHearing Association (ASHA), holds the copyright on all materials published in Perspectives on Augmentative and Alternative Communication, both as a compilation and as individual articles. Please see Rights and Permissions for terms and conditions of use of Perspectives content: http://journals.asha.org/perspectives/terms.dtl Vol. 22, No. 1, pp. 1–61 April 2013

In This Issue From the Coordinator by Mary Ann Lowe ....................................................................... 2 Teaching Partners To Support Communication for Adults With Acquired Communication Impairment by Laura Ball and Joanna Lasker ...................................... 4–15 Training Communication Partners of Adults Who Rely on AAC: Co-construction of Meaning by Amber Thiessen and David Beukelman ....................................................... 16–20 A Systems Approach to Training Potential Communication Partners of People With Aphasia by Nina Simmons-Mackie................................................................................. 21–29 AAC and Communication in the Workplace by David McNaughton and David Chapple ... 30–36 Enhanced Milieu Teaching: Incorporating AAC in Naturalistic Teaching With Young Children and Their Partners by Ann Kaiser and Courtney Wright ................................... 37–50 ImPAACT Program: Partner Instruction by Jennifer Kent-Walsh and Cathy Binger ......... 51–61

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Perspectives on Augmentative and Alternative Communication is a member publication for affiliates of American Speech-Language-Hearing Association Special Interest Group 12, Augmentative and Alternative Communication. Planned publication months are April, June, and September. Since 2012, affiliates of any of ASHA’s 18 SIGs have access to read all SIG Perspectives. To learn more about joining a SIG, visit http://www.asha.org/SIG/join/. Contact Perspectives at [email protected]. Disclaimer of warranty: The views expressed and products mentioned in this publication may not reflect the position or views of the American Speech-Language-Hearing Association or its staff. As publisher, the American Speech-Language-Hearing Association does not warrant or guarantee the accuracy, completeness, availability, merchantability, fitness for a particular purpose, or noninfringement of the content and disclaims responsibility for any damages arising out of its use. Advertising: Acceptance of advertising does not imply ASHA’s endorsement of any product, nor does ASHA accept responsibility for the accuracy of statements by advertisers. ASHA reserves the right to reject any advertisement and will not publish advertisements that are inconsistent with its professional standards.

Vol. 22, No. 1, April 2013 SIG 12 Editor: Sandra Grether SIG 12 2013 Editorial Review Board Members: Meher Banajee ∙ Ann R. Beck ∙ Rebecca L. Eisenberg ∙ Patti Solomon-Rice ∙ Sara Sack SIG 12 CE Content Manager: B. J. Gallagher SIG 12 2013 Coordinating Committee: Mary Ann H. Lowe, SIG Coordinator ∙ Gail Van Tatenhove, Associate Coordinator ∙ Sandra Grether, Perspectives Editor ∙ Mary Ann Abbott ∙ Meher Banajee ∙ Leigh Deussing, ASHA SIG 12 Ex Officio ASHA Board of Directors Board Liaisons: Donna Fisher Smiley, Vice President for Audiology Practice ∙ Gail J. Richard, Vice President for Speech-Language Pathology Practice ASHA Editorial Assistant: Frank Wisswell ASHA Advertising Sales: Pamela J. Leppin ASHA Board of Directors: Patricia A. Prelock, President ∙ Elizabeth S. McCrea, President-Elect ∙ Shelly S. Chabon, Immediate Past President ∙ Donna Fisher Smiley, Vice President for Audiology Practice ∙ Perry F. Flynn, Speech-Language Pathology Advisory Council Chair ∙ Wayne A. Foster, Audiology Advisory Council Chair ∙ Howard Goldstein, Vice President for Science and Research ∙ Carlin F. Hageman, National Student Speech Language Hearing Association (NSSLHA) National Advisor ∙ Carolyn W. Higdon, Vice President for Finance ∙ Barbara J. Moore, Vice President for Planning ∙ Robert E. Novak, Vice President for Standards and Ethics in Audiology ∙ Gail J. Richard, Vice President for Speech-Language Pathology Practice ∙ Shari B. Robertson, Vice President for Academic Affairs in Speech-Language Pathology ∙ Theresa H. Rodgers, Vice President for Government Relations and Public Policy ∙ Neil T. Shepard, Vice President for Academic Affairs in Audiology ∙ Jennifer B. Watson, Vice President for Standards and Ethics in Speech-Language Pathology ∙ Arlene A. Pietranton, Chief Executive Officer (ex officio to the Board of Directors)

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From the Coordinator Mary Ann Lowe Happy Spring! Welcome to this April 2013 edition of Special Interest Group 12 Perspectives on Augmentative and Alternative Communication. During 2013, the SIG 12 will provide 3 issues of Perspectives instead of 4 issues. There has been a schedule change in the months of publications for our SIG. In 2013, the Perspectives will be published in April, June, and September. To accommodate the same number of CEU’s that are offered each year by our SIG, there will be more articles, as well as exam questions. per issue for 2013. Our publication dates for 2014 will return to four issues in the months of January, April, June, and September. In this issue, we highlight the final articles from the presenters of the online conference that was presented in June 2012 on Partner Instruction in AAC. We thank Cathy Binger and Jennifer Kent-Walsh for chairing this spectacular event and for their tireless hours of organization. In this issue, Laura Ball and Joanne Lasker discuss issues of teaching partners to support communication as it relates to clients with acquired impairments. David Beukelman and Tiffany Thiessen, followed by Nina Simmons-Mackie, will explore related topics in their articles focused on adult partner issues for clients with aphasia and neurogenic disorders. David McNaughton and David Chapple then will present an overview of communication skills, partner supports, and preparation activities relevant to employment contexts. Ann Kaiser and Courtney Wright present enhanced milieu teaching in the natural teaching environment. In the final article, Kent-Walsh and Binger will detail the evidence-based ImPAACT program—a communication partner instruction protocol. In this article, they provide a step-by-step approach to working with communication partners that could be used with the communication partners of any client with complex communication needs. Happy reading! Don’t forget that Perspectives provides affiliates with an opportunity to earn Continuing Education Units (CEUs)!

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Teaching Partners to Support Communication for Adults with Acquired Communication Impairment Laura Ball Joanne Lasker Disclosure: Laura Ball has no financial or nonfinancial relationships related to the content of this article. Disclosure: Joanne Lasker has no financial or nonfinancial relationships related to the content of this article.

Abstract For adults with acquired communication impairment, particularly those who have communication disorders associated with stroke or neurodegenerative disease, communication partners play an important role in establishing and maintaining communicative competence. In this paper, we assemble some evidence on this topic and integrate it with current preferred practice patterns (American Speech-Language-Hearing Association, 2004). Our goals are to help speech-language pathologists (SLPs) identify and describe partner-based communication strategies for adults with acquired impairment, implement evidence-based approaches for teaching strategies to communication partners, and employ a Personnel Framework (Binger et al., 2012) to clarify partners’ roles in acquiring and supporting communication tools for individuals with acquired impairments. We offer specific guidance about AAC techniques and message selection for communication partners involved with chronic, degenerative, and end of life communication. We discuss research and provide examples of communication partner supports for person(s) with aphasia and person(s) with amyotrophic lateral sclerosis who have complex communication needs. We know that augmentative and alternative communication (AAC) techniques (both high-tech and low-tech) are effective interventions for adults with acquired communication impairments (Doyle & Phillips, 2011; Garrett & Lasker, 2013). People with acquired neurogenic communication impairments were formerly nondisabled and remember how they were able to communicate without disability. In addition, their family, friends, and colleagues have similar memories and expectations. We also know that AAC technology enables sustained employment for adults with acquired communication impairments (McNaughton, Light, & Groszyk, 2001). The attitudes of persons with disability as well as those close to them are important to the acceptance of AAC technology (Beukelman & Ball, 2002; Lasker & Bedrosian, 2000). We consider communication partners as key AAC Personnel and, therefore, view communication partner training as an integral component of successful AAC interventions. In addition, in a reconceptualized AAC Personnel Framework for assessment, Binger and colleagues (2012) placed AAC Facilitators and Communication Partners as central to the AAC evaluation and intervention process.

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Identifying and Including Communication Partners for Adults With Acquired Communication Impairment In practice, one of the first steps to AAC intervention involves the SLP identifying key AAC personnel. Although few formal procedures exist for this identification process, there are some issues that may prove helpful for clinicians to consider. First, clinicians may wish to identify decision makers and information seekers, thus determining individual roles in the decision-making process. In addition, identifying and discussing attitudes toward AAC, the disabling condition, technology, functional priorities (e.g., walking, talking, communicating, working, retiring) and preservation of identity and roles (e.g., predisability communication skills) often will direct clinicians to the likely AAC facilitators and most frequent communication partners. Discussions about such topics may help inform the team about potential attitude barriers to AAC use. Attitudes of the adults with acquired communication disorders and their communication partners are key to successful AAC outcomes (e.g., success in selection and acceptance of appropriate technology, preserving communication effectiveness, maintaining support across the course of an acquired impairment, and retaining participation in personal and community social roles; Beukelman & Ball, 2002; Lasker & Bedrosian, 2000). For example, when important communication partners do not actively support AAC approaches, individuals with CCN may find it difficult to implement AAC, particularly if the strategy relies heavily on partners. The SLP develops trust through ongoing clinical contacts and by developing a familiar relationship with key personnel (i.e., person with disability, communication partners). Consider that close communication partners often have a shared understanding of daily events and may have created idiosyncratic strategies for successful communication (Murphy, 2004) that may be capitalized on for training or supporting other communication partners. For example, for an adult who uses a combination of alphabet supplementation and responses to a yes/no hierarchy provided by the partner to optimize communication, it can be essential for clinicians to teach partners about timing and strategies so that partners offer hierarchical options in a way that supports the most effective communication. One specific tool to help clinicians identify partners and to determine partners’ role in subsequent AAC intervention is the Circles of Communication Partners component of the Social Networks Inventory (Blackstone & Hunt-Berg, 2003). As part of the Social Networks assessment process, the SLP and the person with CCN use a diagram to identify partners— classified according to their level of closeness to the person with CCN—from “life partners” within the first innermost circle to "strangers" within the 5th outermost circle. Lasker and Donham (2007) used a poster-sized, augmented version of the Circles of Communication Partners diagram, as well as partner-supported conversation techniques, to facilitate participation in this type of assessment discussion with PWA who had limited expressive skills. With these techniques, clinicians identified important partners to incorporate into treatment goals, as well as their current method of communication with the person with CCN and the relative success of that communication method. For example, the diagram and augmented discussion revealed that one adult with aphasia wanted desperately to re-establish ties with his son (within his second circle). Clinicians then proceeded to establish a goal that focused on improving e-mail skills in order to enable this individual to work toward that outcome. The process of Needs Assessment (Lasker, Garrett, & Fox, 2007) is another method that clinicians have employed broadly across adults with acquired impairment to assess partner roles. During this process, clinicians consider and catalog who the client communicates with, about what communicative topics, in what situational contexts, using what communication method, related to what communicative functions, and with what degree of success. This sort of systematic clinical inquiry to determine communication partners and appropriate message topics can help clinicians target personally relevant and meaningful intervention goals.

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Through the process of exploring conversation partners and topics, clinicians should be aware that they are assuming a trusted and privileged role, as they learn extensively about the personal details of their client’s life. Part of the purpose of this assessment is to ensure that messages are selected and stored appropriately within a client’s AAC system. For example, in discussion about including the phrase “I love you” within a message bank for a client with ALS, it became apparent through conversation with the client’s daughter, that the phrase should be stored as “love you much,” which was more typical of the client prior to diagnosis. Had the SLP not known this, the AAC outcome might have been less authentic for this client.

Qualities of “Good” Communication Partners Many researchers who write from a life-participation-based approach to aphasia rehabilitation, an approach that is consistent with the principles of AAC, suggest that skilled communication partners are able to facilitate and support the communication of people with communication impairment and should be considered as tools to provide environmental support and communication access (Kagan, Black, Duchan, Simmons-Mackie, & Square, 2001; LPAA Project Group, 2001; Lyon, 1992). Considerable evidence exists, particularly from the aphasia literature, about what characteristics comprise an “optimal” communication partner (Simmons-Mackie, Raymer, Armstrong, Holland & Cherney, 2010). Many of these characteristics apply also to partners of individuals with significant expressive communication impairment. In general, we understand that “good” partners allow time for adults with acquired impairment to communicate, help to control background noise, are open to alternative methods of communication, and confirm understanding as conversations progress (National Aphasia Association, 2012). In a study by Simmons-Mackie and Kagan (1999), researchers asked observers to rate “good” and “poor” partners when communicating with adults with aphasia. Results indicated that the discourse patterns of the “best” partners contained more acknowledgements (e.g., “mhm”, head nods) and congruent overlap (e.g. shaking head in unison with person with aphasia), but fewer markers that “blocked” the conversation such as “well.” Another pattern depicted in the discourse of the “best” communication partners was accommodation to nonverbal methods of interaction (e.g., gestures such as “thumbs up‟) and strategies that allowed “face-saving” for the PWA during clarification sequences (i.e., using clarifying questions and guesses during repair sequences to avoid extensive and prolonged breakdown). The authors suggest that these specific discourse behaviors are not necessarily what should be trained in all partners, as they tend to arise directly from the specific dyadic context. Instead they stress the focus on a collaborative interaction, in which partners work to acknowledge the essential competence of the communicator rather than focusing primarily on the disability.

Does Communication Partner Training Work? In a meta-analysis of communication partner training literature in aphasia, SimmonsMackie and colleagues (2010) concluded that interventions focused on the communication dyad, as well as interventions focused solely on the communication partner, yielded positive outcomes. The concept of “conversational coaching” exists as a tool for helping individuals with aphasia and their communication partners who are using primarily spoken language to communicate. Hopper, Holland, and Rewega (2010) found that conversational coaching resulted in a greater number of concepts communicated in storytelling tasks and improved social validation judgments of the dyads. Some researchers have taught PWA to communicate main ideas first, use alternate strategies to communicate, correct incorrect information, and indicate to the partner “you’re close.” In combination with strategies directed to the PWA, researchers taught partners supportive conversational behaviors, such as asking the main idea first, using Augmented Input, confirming yes/no visually, and summarizing information frequently. Other studies have demonstrated success in teaching partners to use

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acknowledgment in conversation and to clarify communication sequences explicitly (Lyon et al., 1997). Despite the fact that many of these studies reveal positive outcomes by teaching adults with acquired impairment and their partners to employ good basic conversational skills, many partners do not use these skills unless explicitly taught. The reasons for this may be habitual or attitudinal; partners simply may not think of these strategies or may be reluctant to alter the methods they typically have used to communicate with the individual. In most instances, a period of coaching or adjustment may be useful.

Research Evidence About Partner Preferences and Behaviors Next, we discuss research projects involving adults with acquired complex communication impairments (e.g., ALS, stroke) and communication partners to gain insight into factors influencing successful AAC assessment and treatment outcomes. This evidence addresses a series of questions to consider when creating AAC systems and providing training, both for individuals with complex communication needs and communication partners. Attention Allocation and Intelligibility In a study examining communication partners’ use of attention skills to communicate with individuals with reduced intelligibility, Beukelman and colleagues (2011) found that communication partners systematically increase the amount of attention they allocate to utterances as speech intelligibility decreases from 100% to 75%. Attention allocation peaks along this decline between 80–75% intelligibility, at which point communication partners expend their highest level of effort to understand the impaired speech productions. When intelligibility drops below the 80–75% range, communication partners become reluctant to communicate with the person due to a reported high perceptual load described particularly when involving complex listening tasks (e.g., high cognitive load, complex content) and long conversational exchanges where fatigue becomes a factor that obstructs ongoing allocation of increased attention to understand speech of reduced intelligibility. Communication Effectiveness and Intelligibility There is a high level of agreement between person(s) with amyotrophic lateral sclerosis (pALS) and communication partners regarding the level of communication difficulty related to situation, environment, and interactions with individuals (e.g., familiar/unfamiliar person, quiet/noise, phone/car). Communication partners agree with pALS, ranking lengthy conversations, speaking to a group, noise, and distance as difficult situations that negatively impact communication effectiveness (Ball, Beukelman, & Pattee, 2004). Evidence indicates that pALS express a need for AAC technology to support their natural speech when intelligibility is in the 80–90 percent range or lower (Ball, Beukelman, & Pattee, 2002). Communication Effectiveness & Level Difficulty: Environment and Communication Partners There is a high level of agreement between pALS and communication partners regarding level of communication difficulty based on environmental factors and communication partners. Ball and colleagues (2004) asked a group of pALS and their communication partners to rankorder communication situations by difficulty and found that the easiest communication situation involved interaction with a familiar person in a quiet environment and the more difficult involved communicating in a noisy environment, to a group, and in a lengthy conversation. Although this result may not be consistent across adult acquired disabilities (i.e., Parkinson’s disease), there is evidence that communication partners generally agree with the person with CCN on effectiveness of communication in various environments (e.g., quiet, noise, phone, car, distance, group, long conversation, familiar, stranger, child). Communication Partners’ Attitudes Toward Narrative Message Delivery: Message Generation In a two-party study, Richter, Ball, Beukelman, Lasker, & Ullman (2003) first asked communication partners to place their preferred method of message formulation for conveying narratives in rank order of perceived communication competence and effectiveness (of the

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person with complex communication needs). They presented the communication partners with three message generation techniques: whole narrative (in which the entire story was presented at once), sentence-by-sentence (in which the story was presented one sentence at a time), and word-by-word (in which the story was presented one word at a time). The researchers identified that communication partners perceived that people with complex communication needs who used whole narrative and sentence-by-sentence narrative delivery were highest on communication competence and effectiveness. Unfamiliar peer communication partners preferred sentence-by-sentence for communication competence and effectiveness. The second component examined the message delivery method in considering willingness to participate in a conversation, communication partners indicated greater willingness during whole narrative and sentence-by-sentence delivery. Overall, the partners preferred whole narrative and sentenceby-sentence techniques equally and considered word-by-word least preferred. Communication Partner Attitudes Toward Narrative Message Delivery: AAC Mode Richter and colleagues (2003) examined the attitudes of pALS, caregivers, and communication partners toward three modes of communication. The three modes included dysarthric natural speech, a communication book with a laser pointer and no voice output, and scanning message formulation via a head switch and synthesized voice output. Communication partners’ judgments of communicative competence, effectiveness, comfort, willingness to communicate, and intelligibility were analyzed. Overall rankings indicated that pALS and caregivers agreed that they preferred communication with dysarthric natural speech, followed by the communication notebook, and finally the synthesized speech condition. For narrative story-telling, communication partners prefer an augmented communication modality (i.e., communication book, synthesized voice output device); they perceive the speaker as more communicatively competent and indicate greater willingness to participate in conversation. Communication partners indicated that they are least comfortable with communication using dysarthric natural speech. Caregivers indicated that the synthesized voice output mode is easiest to understand, whereas communication partners perceived that the communication book was easiest to understand. This may be a function of experience with the synthesized voice output, which may require some adjustment to become accustomed to the output for greater intelligibility. Communication Partner’s Report of Communication Purposes: Technology Importance Fried-Oken and colleagues (2006) asked communication partners to report on frequency, mode, and importance of communication purposes for pALS. The communication partners subsequently worked with the pALS to create a series of specific messages relevant to the most important (self-designated) communication purposes (e.g., giving instructions/direction, exchanging information, being funny, religious/philosophical issues). When the communication purposes were established, the communication partners then indicated the importance of AAC technology for communicating the messages. Communication partners indicated that AAC technology was either mandatory or desirable for getting needs met, giving instructions, clarifying needs, staying connected with friends and colleagues to enhance quality of life, discussing important issues and health care, and for use of humor. The investigators suggested that interventionists facilitate the use of AAC technology for highpriority communication purposes by identifying potential communication partners and environments where communication is likely to occur and carefully assessing the kinds of messages pALS need to achieve their high-priority communication purposes. They suggest a checklist (Fried-Oken et al., 2006) to identify discrepancies between communication partners’ interaction expectations and those of the person with CCN. End of Life and Communication Partners Many adults with acquired communication impairments use AAC technology for daily communication until within 1 month of their death (Ball et al., 2007) and there is evidence that 46% of pALS used AAC technology during the last week of their life. There may be accompanying changes in medical and personal care providers (e.g., hospice, nursing home, in-

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home care providers) and an increased use of low- or no-technology modes (e.g., eye linking, facial/eye gestures, partner dependent scanning). For this reason, new communication partner training may be a vital service to ensure that communication partners are effective at supporting communication. In addition to the focus on documenting system use, some researchers have investigated the most frequently cited topics and communication functions at end of life. In the study described in the previous section on technology use, Fried-Oken and colleagues (2006) found that important communication functions towards the end of life included getting needs met, clarifying needs with caregivers, giving instructions or directions to others, and staying connected with family and friends. These findings are consistent with a study conducted by King and Lasker (2013) that included 80 hospice workers and 5 adult clients who were enrolled in hospice programs. Participants completed surveys regarding important message topics and potential communication partners at the end of life. In response to both rating scale and open-ended questions, hospice workers cited the topics of reminiscence, pain or symptom management, and relationships among the most frequently discussed topics. These data suggest that, in terms of message selection and message banking for adults at end life, partners and clinicians may wish to consider programming messages in these particular content areas.

AAC Strategies for Adults with Acquired Communication Impairments What follows is a brief summary of several AAC strategies useful to supporting adults with acquired communication impairments. In most of these low-tech strategies, the communication partner takes the lead in implementation. Many of these strategies may be familiar to readers from prior research on “partner-dependent” vs. “independent” communicators with aphasia (Garrett & Lasker, 2006; Lasker et al., 2007). Partner-dependent individuals with aphasia are those who rely on their conversational partners to help them manage informational demands of conversation and also to provide communication choices within highly familiar contexts. Adults with dysarthria also may be considered partner dependent, in that they rely on partners in different contexts and at different times. For example, an adult with ALS may use an eye-gaze speech generating device to access and formulate messages independently when seated in his recliner, but may require partner-based eye-linking while lying in bed. The strategies we describe below could be helpful to facilitate communication with partner-dependent adults with aphasia as well as adults with dysarthria who are temporarily or permanently partner-dependent. Augmented Input In the Augmented Input strategy (Garrett & Beukelman, 1992, 1998; Sevcik, Romski, & Wilkinson, 1991; Wood, Lasker, Siegel-Cause, Beukelman, & Ball, 1998) a communication partner supports the comprehension of the communicator by supplementing spoken language using gesture, written key words, drawings, and diagrams—all of which the partner produces as the conversation occurs “in real time.” The visual materials cannot be developed ahead of time because they arise from the specific communication context. For example, a partner might be communicating to an adult with aphasia, “I will meet you in 10 minutes outside the parking garage” and may augment this spoken utterance by writing the key words “meet” and “outside” and by drawing an arrow or gesturing in the appropriate direction. Or the partner may point to his watch or draw a clock to indicate 10 minutes. For some people with receptive or attentional impairments, the combination of a slowed rate and multimodal stimulation (pairing visual and auditory modalities) helps them to understand and ultimately respond to the message. The “burden” of clarifying the message and resolving the communication breakdown falls to the partner when communicating with adults who have aphasia. Augmented Input is frequently used in combination with another strategy known as the Written Choice Conversation Strategy. Written Choice Conversation Strategy

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Another widely used strategy by partners in conversation with people with aphasia is known as the Written Choice Conversation Strategy (Garrett & Beukelman, 1992, 1995; Lasker, Hux, Garrett, Moncrief, & Eischeid, 1997). This strategy can be used in combination with Augmented Input, but whereas Augmented Input is intended to support understanding, Written Choice is intended to provide a response pool to support expression. This technique requires the partner to pose a conversational question to a communicator with an acquired disorder and, if the communicator is unable to respond, the partner then generates written key-word response options pertinent to the conversational topic. The communicator participates by pointing to the choices in order to make his or her opinions and preferences known. The questions and topics can be impersonal (e.g., asking about what the person with aphasia ate for breakfast) or more personal and specific (e.g., asking about memories, important events, or questions related to personal life preferences and decisions). This approach serves to lengthen and deepen the interaction with adults who may be very limited in the spoken words they can use in conversation. Within the Written Choice Conversation Strategy, the partner may scaffold the conversation by providing items in a potential response pool and/or offering graphic rating scales for the adult to point to that are prepared ahead of time. To use the graphic rating scales component of this approach, the partner poses a question that requires a response that would fit on a scale. These questions may relate to anything that can be quantified, such as a question about a degree of preference or how strongly a person with aphasia feels about something. The partner poses the question, sets up the end points of the scale, and then asks the communicator to indicate their response on the scale. Once the client points to a particular physical point on the written scale, the clinician circles it and the conversation moves on. It should be noted that many Written Choice conversations begin with the partner asking a sincere, open-ended question. This technique works best when it truly serves the purposes of communication, so ideally the partner may not, in fact, know the answer to the question posed. The primary purpose is to engage the communicator and provide a response pool because we know that partners often feel uncomfortable conversing with those who have very limited language. Because this is intended to be a dynamic conversational process, communication partners do not prepare choices ahead of time. Tagged Yes/No Communicators with severe aphasia often have difficulty answering yes/no questions in a clear and unambiguous manner. Because of apraxia, for example, they may have trouble coordinating their head movements to signify “yes” and “no.” Or, they may not know how to answer the question because the grammatical structure of questions does not explicitly tell them to answer with “yes/no” versus a more specific word or phrase. Other times, communicators simply don’t understand the question. The simple strategy of “tagging” the question can bypass the first two problems. Partners add the phrase “yes…or…no?” to the ends of their yes/no questions. They simultaneously model the head movements. This effectively provides the communicator with a narrow pool of choices for how to respond within the context of a conversation (Garrett & Lasker, 2013). Eye Linking/Pointing Eye linking is a procedure that involves use of a transparent communication board. For this, the communication partner holds a communication board in a position to enable both communicators to view all of the messages. The communication partner views the messages from behind, so that the communicator may read the messages readily. Next, the communicator directs her/his gaze at the desired message and the communication partner moves the board until their gaze meets that of the communicator to confirm the selection of the intended message. Partner Dependent Scanning The communication partner scans through each line of a communication board/book by initiating scanning line by line down the page: “Is it in line 1? Line 2?”; then upon receiving

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an affirmative response, moves across the columns “a? b? c? d?” until affirmative response is received again. We provide an example of this procedure in Figure 1. Figure 1. Partner Dependent Scanning Procedure With Basic Alphabet Board

Instructions for use with example: 1. First, scan down the lines. “Is it line 1? Line 2? Yes! 2. Next, scan across the columns. “ Is it F? G? yes! “ 3. Begin again with the same procedure until the word/message is complete. For long messages, the communication partner may find a notepad is helpful to write the letters and not get lost mid-utterance. “Is it line 1? Line 2? Line 3? Yes! Is it K? L? M? N? O? yes! Do you mean Go? Yes!” Yes/No Hierarchy The communication partner begins with a broad set of questions that are narrowed with subsequent responses. The questions are all structured so that they may be answered with a yes/no response. For example: 1. “Do you want to tell me something?” (moves eyes left to indicate yes) 2. “Do you want something?” (moves eyes left to indicate yes) 3. Communication partner then voices aloud from the list of items preferred by the person, waiting for a yes/no response following each. “Do you want something to drink? (moves eyes right to indicate no) to read? (moves eyes left to indicate yes) Do you want your novel? (moves eyes right to indicate no) the newspaper? (moves eyes right to indicate no) your magazine? (moves eyes left to indicate yes).” Facial Movement/Gestures A gesture dictionary (Beukelman & Mirenda, 2013) may be helpful who have an array of facial gestures that may be considered nonstandard. To reduce potential communication breakdowns that may result from an unfamiliar gesture, it may be helpful to compile descriptions of the gestures along with their meanings and suggested responses. In Figure 2, we illustrate one example of a gesture dictionary for a person with limited physical movements.

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Figure 2. Gesture dictionary example Communicative Behavior: What the person does (e.g., gesture, sound)

Function: What it means

Consequence: What communication partner does (if obvious, this is unnecessary)

Shakes toe side to side

Hi, nice to meet you – Let me shake your hand

Shake his hand

Eyes move to left

Yes!

Situational response

Eyes move to right

No!

Situational response

Throat clearing

I’m afraid

Remove from situation

Alphabet Supplementation Although not strictly a partner strategy, this strategy is used by the person with CCN who has sufficient movement and literacy skills to identify the first letter of each word spoken on an alphabet board or other display while simultaneously saying the word. Instead of the time-consuming technique of spelling an entire word, indicating the first letter while saying the whole word may increase intelligibility and communication efficiency. Hanson and colleagues (2004) reported that alphabet supplementation increased sentence intelligibility by 25.5% and single word intelligibility by 10%. Beukelman and Mirenda (2013) indicated that alphabet supplementation should be considered if the individual can learn to implement it in conversational interactions and there is a positive impact on speech intelligibility. Teaching Strategies to Partners of Adults With Acquired Communication Disorders From the field of early intervention (Woods & Brown, 2011), models exist to describe how best to teach families, who are the most frequent communication partners of young children, to use supportive communication strategies. These models suggest a systematic method for clinicians to teach partners of adults with acquired communication disorders techniques to enhance and improve communication. Woods, Wilcox, Friedman, and Murch (2011) describe the steps of the process in terms of everyday communication routines and list the major steps as preparing to teach strategies, application and feedback, and mastery. To present these learning stages, we offer an example from the world of aphasia, in which we may be trying to teach a partner of a PWA to use Augmented Input and Written Choice Conversation Strategy. The clinician may begin by first observing the conversational interaction between the communicator and partner and determining whether or not these particular strategies could potentially be useful to improve communication. This may require multiple observation opportunities, as well as discussion with the dyad about communication contexts and needs. Optimally, the participants all should agree that these are potentially useful communication strategies that have the potential to address a pressing problem or communication need. Then, the clinician would begin explicit direct teaching with the partner to demonstrate these skills. In the application and feedback stage, the clinician would conduct “joint interaction” with the dyad that included guided practice to support the partner in implementing these new communication strategies, with immediate and specific feedback regarding the partner’s use of these skills. Caregiver practice, without the clinician present, may follow with the clinician offering specific feedback. During the mastery stage, the clinician would support the partner by helping them problem-solve specific communication events (e.g., asking, “how did you think that worked when you offered written key words to clarify that you wanted to clean out the garage?” and “why do you think the Augmented Input was less successful in this interaction?”) and encouraging them to reflect on their implementation of these techniques. Researchers suggest that implementing new communication behaviors works best if it is taught explicitly within the context of daily routines (Kashinath, Woods, & Goldstein, 2006).

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Final Considerations Adults with acquired communication impairments have many AAC options that can facilitate ongoing functional communication. Adults with limited expressive repertoires, whether caused by aphasia or dysarthria, may benefit from partner-supported techniques. Training to support the effective use of specific strategies is essential. In this paper, we suggest that the AAC assessment and intervention processes include identification of strategies to increase functional communication, determine key communication partners, and implement client/partner training strategies. Although there has been some research published on the efficacy of partner training to support children’s communication development (Binger, KentWalsh, Berens, Del Campo, & Rivera, 2008; Binger, Kent-Walsh, Ewing, & Taylor, 2010; KentWalsh, Binger, & Hasham, 2010; Kent-Walsh, Binger, & Malani, 2010), researchers and clinicians may wish to focus on increasing the evidence base to document the efficacy of particular strategies for adults with acquired disorders and their communication partners. In addition, many of the same strategies may have equal applicability for other populations of individuals who use AAC; as a result, researchers could expand investigation into the effectiveness of these strategies with others. We believe it is imperative that all members of the AAC team agree on the value of these tools and that these relatively simple partner-supported strategies are taught explicitly to partners and clients with complex communication needs.

References American Speech-Language-Hearing Association. (2004). Preferred practice patterns for the profession of speech-language pathology [Preferred Practice Patterns]. Available from www.asha.org/policy Ball, L. J., Anderson, E., Bilyeu, D. V., Pattee, G. L., Beukelman, D. R., & Robertson, J. (2007). Duration of AAC technology use by persons with ALS. Journal of Medical Speech-Language Pathology, 15, 371–381. Ball, L. J., Beukelman, D. R., & Bardach, L. (2007). Amyotrophic lateral sclerosis. In D. R. Beukelman, K. L. Garrett, & K. M. Yorkston (Eds.), Augmentative communication strategies for adults with acute or chronic medical conditions (pp. 287–316). Baltimore, MD: Paul H. Brookes. Ball, L. J., Beukelman, D. R., & Pattee, G. L. (2004a). Acceptance of augmentative and alternative communication technology by persons with amyotrophic lateral sclerosis. Augmentative and Alternative Communication, 20, 113–122. Ball, L. J., Beukelman, D. R., & Pattee, G. L. (2004b). Communication effectiveness of individuals with amyotrophic lateral sclerosis. Journal of Communication Disorders, 37, 197–215. Beukelman, D. R., & Ball, L. J. (2002). Improving AAC use for persons with acquired neurogenic disorders: Understanding human and engineering factors. Assistive Technology, 14, 33–44. Beukelman, D. R., Childes, J., Carrell, T., Funk, T., Ball, L. J., & Pattee, G. L. (2011). Perceived attention allocation of listeners who transcribe the speech of speakers with amyotrophic lateral sclerosis. Speech Communication, 53, 801–806. Binger, C., Ball, L. J., Dietz, A., Kent-Walsh, J., Lasker, J., Lund, S., McKelvey, M., & Quach, W. (2012.) Personnel roles in the AAC assessment process. Augmentative and Alternative Communication, 28, 278– 288. Binger, C., Kent-Walsh, J., Berens, J., Del Campo, S., & Rivera, D. (2008). Teaching Latino parents to support the multi-symbol message productions of their children who require AAC. Augmentative and Alternative Communication, 24, 323–338. Binger, C., Kent-Walsh, J., Ewing, C., & Taylor, S. (2010). Teaching educational assistants to facilitate the multi-symbol message productions of young students who require AAC. American Journal of SpeechLanguage Pathology, 19, 108–120. Blackstone, S. W., & Hunt-Berg, M. (2003). Social networks: A communication inventory for individuals with complex communication needs and their communication partners. Monterey, CA: Augmentative Communication.

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Doyle, M., & Phillips, B. (2001). Trends in augmentative and alternative communication use by individuals with amyotrophic lateral sclerosis. Augmentative and Alternative Communication, 17, 167–178. Friedman, M., Woods, J., & Salisbury, C. (2012). Caregiver coaching strategies for early intervention providers: Moving toward operational definitions. Infants & Young Children, 25(1), 62–82. Fried-Oken, M., Fox, L., Rau, M. T., Tullman, J., Baker, G., Hindal, M., … & Lou, J. S. (2006). Purposes of AAC device use for persons with ALS as reported by caregivers. Augmentative and Alternative Communication, 22, 209–221. Garrett, K., & Beukelman, D. (1992). Augmentative and alternative communication approaches for individuals with severe aphasia. In K. M. Yorkston (Ed.), Augmentative and alternative communication in the medical setting (pp. 245–321). Communication Skill Builders: Tucson, AZ. Garrett, K., & Beukelman, D. (1995). Changes in the interaction patterns of an individual with severe aphasia given three types of partner support. In M. Lemme, (Ed.), Clinical Aphasiology 23 (pp. 237–251). Austin, Tx: Pro-Ed. Garrett, K. L., & Beukelman, D. R. (1998). Adults with severe aphasia. In D. R. Beukelman & P. Mirenda (Eds.), Augmentative and alternative communication: Management of severe communication disorders in children and adults (pp. 465–499). Baltimore, MD: Paul H. Brookes. Garrett, K. L., & Lasker, J. P. (2013). Adults with severe aphasia and apraxia of speech. In D. Beukelman & P. Mirenda (Eds.), Augmentative and alternative communication: Supporting children and adults with complex communication needs (4th ed.) (pp. 405–445). Baltimore, MD: Paul H. Brookes. Hopper, T., Holland, A., & Rewega, M. (2002). Conversational coaching: Treatment outcomes and future directions. Aphasiology, 16, 745–761. Kagan, A., Black, S. E., Duchan, J. F., Simmons-Mackie, N., & Square, P. (2001). Training volunteers as conversation partners using “Supported Conversation for Adults With Aphasia” (SCA): A controlled trial. Journal of Speech, Language, and Hearing Research, 44, 624–638. Kashinath, S., Woods, J., & Goldstein, H. (2006). Enhancing generalized teaching strategy use in daily routines by parents of children with autism. Journal of Speech, Language, and Hearing, 49, 466–485. Kent-Walsh, J., Binger, C., & Hasham, Z. (2010). Effects of parent instruction on the symbolic communication of children using AAC during storybook reading. American Journal of Speech-Language Pathology, 19, 97–107. Kent-Walsh, J., Binger, C., & Malani, M. (2010). Teaching partners to support the communication skills of young children who use AAC: Lessons from the ImPAACT program. Early Childhood Services, 4(3), 155– 170. Lasker, J. P., & Bedrosian, J. L. (2001). Promoting acceptance of augmentative and alternative communication by adults with acquired communicative disorders. Augmentative and Alternative Communication, 17, 141–153. Lasker, J. P., & Donham, A. (September, 2007) Partner-dependent techniques for using the Social Networks Inventory: An example of severe aphasia. Lexington, KY: Clinical AAC Conference. Lasker, J. P., & Garrett, K. L. (2006) Using the Multimodal Communication Screening Test for Persons with Aphasia (MCST-A) to guide the selection of alternative communication strategies for people with aphasia. Aphasiology, 20(2/3/4), 217–232. Lasker, J. P., Garrett, K. L. & Fox, L. E. (2007). Severe aphasia. In D. R. Beukelman, K. L. Garrett, & K. M. Yorkston, (Eds.), Augmentative communication strategies for adults with acute or chronic medical conditions (pp. 163–206). Baltimore, MD: Paul H. Brookes. Lasker, J. P., Hux, K., Garrett, K., Moncrief, E., & Eischeid, T. (1997). Variations on the written choice communication strategy for individuals with severe aphasia. Augmentative and Alternative Communication, 13, 108–116. Lyon, J. G., Cariski, D., Keisler, L., Rosenbek, J., Levine, R., Kumpula, J., … Blanc, M. (1997). Communication partners: Enhancing participation in life and communication for adults with aphasia in natural settings. Aphasiology, 11, 693–708. LPAA Project Group (in alphabetical order): Chapey, R., Duchan, J., Elman, R., Garcia, L., & Kagan, A. L. J. (2001). Life participation approach to aphasia: A statement of values for the future. In R. Chapey (Ed.),

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Language intervention strategies in aphasia and related neurogenic communication disorders (pp. 278– 289). Baltimore, MD: William and Wilkins. McNaughton, D., Light, J., & Groszyk, L. (2001). “Don’t give up”: Employment experiences of individuals with amyotrophic lateral sclerosis who use augmentative and alternative communication. Augmentative and Alternative Communication, 17, 179–195. Murphy, J. (2004). “I prefer contact this close”: Perceptions of AAC by people with motor neurone disease and their communication partners. Augmentative and Alternative Communication, 20, 259–271. National Aphasia Association. (n.d.). Guideposts for communicating. Retrieved from http://www.aphasia.org/docs/Guideposts.PDF Richter, M., Ball, L. J., Beukelman, D. R., Lasker, J. P., & Ullman, C. (2003). Attitudes toward communication modes and message formulation techniques used for storytelling by people with amyotrophic lateral sclerosis. Augmentative and Alternative Communication, 19, 170–186. Sevcik, R., Romski, R., & Wilkinson, K. (1991). Roles of graphic symbols in the language acquisition process for persons with severe cognitive disabilities. Augmentative and Alternative Communication, 7, 161–170. Simmons-Mackie, N., & Kagan, A. (1999). Communication strategies used by 'good' versus 'poor' speaking partners of individuals with aphasia, Aphasiology, 13(9–11), 807–820. Wood, L. A., Lasker, J. P., Siegel-Cause, E., Beukelman, D. R., & Ball, L. (1998). Input framework for augmentative and alternative communication. Augmentative and Alternative Communication, 14, 261–267. Woods, J. J., & Brown, J. A. (2011). Integrating family capacity-building and child outcomes to support social communication development in young children with autism spectrum disorder. Topics in Language Disorders, 31, 235–246. Woods, J. J., Wilcox, M. J., Friedman, M., & Murch, T. (2011). Collaborative consultation in natural environments: Strategies to enhance family-centered supports and services. Language, Speech, & Hearing Services in the Schools, 42, 379–392.

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Training Communication Partners of Adults Who Rely on AAC: Co-Construction of Meaning Amber Thiessen David Beukelman Disclosure: Amber Thiessen has no financial or nonfinancial relationships related to the content of this article. Disclosure: David Beukelman has no financial or nonfinancial relationships related to the content of this article.

Abstract In this article, we summarize a presentation on the training of AAC communication partners at the SIG 12 Virtual Conference (2012). We describe the characteristics of effective communication partners. We also will discuss adult learning principles and learning mode preference as they relate to training of AAC communication partners. In this article, we summarize a presentation we did for the American Speech-LanguageHearing Association, Special Interest Group 12 Virtual Conference in May of 2012. In this presentation, we focused on the training of communication partners of adults who rely on augmentative and alternative communication (AAC). By training, we refer to both the instruction and practice needed to support the communication of those who rely on AAC. Several types of AAC personnel (Beukelman, Ball, & Fager, 2008) typically have not completed formal education or professional preparation in AAC, and these people benefit from training to interact with people who rely on AAC. Communication facilitators are those who provide longterm communication support, in that they are responsible for AAC system upkeep, training unfamiliar communication partners to interact effectively with the individual who relies on AAC, and maintaining relationships with various people and entities involved in communication support. Communication partners typically interact with the individual who relies on AAC; however, they are not responsible for system maintenance and are not caregivers (Blackstone & Hunt Berg, 2003). Finally, caregivers must interact accurately and efficiently with the individual who relies on AAC in order to provide personal and health care.

Social Roles To highlight the social roles people with AAC needs prefer, we summarize a recent article by Dalemans, de Witte, Wade, and van den Heuvel (2010), who examined the social participation patterns of people with aphasia. The researchers found several themes, including the importance of (a) maintaining social closeness to family and friends; (b) knowing what is going on in their social networks; (c) being involved in activities important to them; (d) taking part, being engaged, and participating; (e) not being a burden; and (f) being respected. In order for this level of social engagement to be maintained by adults with complex communication

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needs, people within their social networks need to be prepared to support their communication efforts.

Characteristics of Effective Communication Partners Effective communication partners are essential, as they assist people who rely on AAC in maintaining their previously held social roles by supporting their communication needs. Effective communication partners understand the importance of turn-taking and engaging in balanced conversations. They ask questions, but also allow the individual with AAC to reciprocate. To do this, effective communication partners focus on the messages of the individual who relies on AAC and allow them to ask and answer questions on a more equal level. Effective communication partners learn to share in topic shifts, rather than dominating the topics that are discussed. Finally, effective communication partners learn to create shared communication spaces as they co-construct messages by using a range of communication supports including photos, visual scenes, and remnants (e.g., newspaper clippings, bulletins, programs, web content on mobile technology) that are relevant to the interaction. In other words, effective communication partners learn shared acceptance of the communication style of the individual who relies on AAC. For example, some like to joke or to provide information, whereas others are more shy and reserved and prefer one-on-one interactions with close friends and family (Dalemans et al., 2010). The first step in planning partner training is to have the partners identify and shift toward the communication goals, styles, and preferences of the individual who relies on AAC. They need to share the goals related to the restoration of natural speech, the use of compensatory communication strategies to take the place of natural speech, or multimodal communication supports to supplement their residual, natural speech. In addition, they need to learn about the abilities of the individual who relies on AAC and to understand the support they need in terms of equipment setup, modification, and maintenance. Communication partners also need to learn new communication strategies, both low- and high-technology strategies, and to settle for “less than perfect” speech and AAC performance, as long as the message is communicated.

Communication Partners Who Do Not Accommodate Some communication partners experience difficulty accommodating to the style of the individual who relies on AAC. Light, Binger, and Kelford Smith (1994) identify several of the tendencies of these individuals. They tend to ask a high number of closed-ended questions such as yes/no, multiple choice, and single-word answer questions. Communication partners who do not accommodate often take the majority of conversational turns and interrupt frequently, thus providing people who rely on AAC with few opportunities for conversation initiations, or even responses. Additionally, some communication partners focus on the AAC system during interaction, rather than the individual who relies on AAC.

Communication Partner Training When training communication partners, there are two different individuals, the interventionist and the new communication partner, and they each have their own learning style preference. There is a tendency for interventionists to provide training in style that they learned and that they prefer. However, we have learned through the years that a number of factors influence learning style. Principles of Adult Learning The three principles of adult learning that we emphasized are (1) the need to know, (2) prior experience and knowledge, and (3) readiness to learn (Knowles, Holton, & Swanson, 1998).

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Adult learners have a strong need to learn information that is relevant and useful to them. In other words, the content must be important, have utility in their lives, and be relevant to the needs of the particular individual who relies on AAC with whom they are interacting. As such, anyone training adult learners should inform the learners about the content they will be covering, why that content is relevant, and how the interventionist will teach that content in terms of training methods and expectations. Adults come to new learning with prior experiences. They have individual differences, unique prior content resources, and learning biases that shape and inhibit new learning and learning preferences. For example, someone who is very familiar with technology probably will have different learning style preferences compared to an individual with little or no technology learning experience. Adults’ readiness to learn is influenced by many factors. Life experiences tend to create this readiness to learn. For communication partners, the presence of an individual with AAC needs in their lives introduces them to the need to learn content and strategies involving communication. Adults need direction and support. If adults feel competent because of prior experience, they are more likely to be independent in their learning. However, if their confidence and, therefore, their self-efficacy, is low, they will be more dependent and will need more direction than those with greater confidence or self-efficacy. Learning Mode Preferences Learning mode preference refers to the environment or learning style individuals prefer when they enter a new learning task. Previous researchers focused on AAC personnel learning (Beukelman, Burke, Ball, & Horn, 2002; Beukelman, Hanson, Hiatt, Fager, & Bilyeu, 2005; Burke, Beukelman, Ball, & Horn, 2002) have concentrated on four distinct learning mode preferences that we discuss below. Adults with an independent learning preference prefer to learn alone with appropriate resources. For example, they may just want an AAC device, the manual, and access to related websites. They enjoy learning on their own, rather than in a small group or through direct instruction, although they may wish to ask clarifying questions of the trainer. Many AAC specialists have strong independent learning tendencies (Burke et al., 2002). Thiessen and Beukelman (2011) investigated the learning mode preferences of potential AAC facilitators, that is, adults with no AAC experience who were not AAC facilitators. The results revealed that male participants preferred to learn independently, whereas female participants preferred to learn in small groups. Those with small group learning preferences tend to be social learners. They enjoy learning with others, to learn from other learners, to share ideas, and to coach each other. They tend not be reluctant to reveal their strengths and limitations to the group. Those with case study learning preferences want to learn information that is relevant to a particular individual with AAC needs. They want to learn with a specific individual in mind. They may have independent or small-group learning preferences as well, but they want their learning to be relevant to a particular person or situation. Thiessen and Beukelman (2011) reported that potential adult facilitators of both genders reported a relatively strong preference to learn through the case study mode. Those with step-by-step learning preferences wish to receive detailed instruction from their trainer in a learner supportive learning environment. These individuals often have lower self-efficacy about learning a specific task or content than the independent or small group learner. Earlier researchers have shown that AAC specialists tend not to prefer step-by-step learning situations. Thiessen and Beukelman (2011) observed that some potential AAC facilitators have a strong preference for step-by-step instruction, whereas others do not. Researchers have not found any overall group differences based on gender or age. However, because some AAC facilitators may have a strong preference for step-by-step training, it is a

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good idea to identify such individuals before engaging them in an independent or small-group training experience that probably will be uncomfortable for them. Burke and colleagues (2002) published a learning mode questionnaire that consists of four Likert-style questions. Interventionists can use this tool to assess which learning environments individuals prefer. It is quick, efficient way to identify the learning mode profile of people who are learning to become communication partners. Training Communication Partners at a Distance Developments in remote access technology have allowed for more training at a distance than was previously possible. Quinn, Beukelman, and Thiessen (2011) investigated the preference and accuracy of young adults for two types of instruction, remote access (screen sharing software) with simultaneous phone contact and side-by-side instruction when learning an unfamiliar AAC software application. They found that the accuracy of learning performance was similar for both conditions; however, these participants preferred the remote access condition. This is an initial study, but it does show promise for training communication partners at a distance. Of course, when AAC communication partners live at a distance from the trainer, remote training may be the only option. Awareness of Cultural Difference Depending upon the potential communication partner and the individual who relies on AAC, the interventionist must consider cultural issues when providing communication partner training. For example, both parties will need to agree about the language used in various AAC strategies. In addition, interventionists and communication partners should review icons, images, and gestures to determine if these items are culturally acceptable. Finally, interventionists should take care to determine that the training environment, participants, and mode are culturally acceptable and appropriate for the individual(s) receiving the training. People who rely on AAC benefit from effective communication partners. Without training, these partners may resort to interaction and support strategies that negatively affect the communication quality and satisfaction experienced those who use AAC. A number of different factors potentially influence the learning mode preferences of communication partners. We encourage AAC interventionists to identify and respond to these preferences, as well as cultural differences, when providing communication partner training.

References Beukelman, D., Ball, L., & Fager, S. (2008). A personnel framework for adults with acquired complex communication needs. Augmentative and Alternative Communication, 24, 255–267. Beukelman, D., Burke, R., Ball, L., & Horn, C. (2002). AAC technology learning: Part 2—Pre-professional students. Augmentative and Alternative Communication, 18, 250–254. Beukelman, D., Hanson, E., Hiatt, E., Fager, S., & Bilyeu, D. (2005). AAC technology learning: Part 3— Regular AAC team members. Augmentative and Alternative Communication. 21, 187–194. Blackstone, S., & Hunt Berg, M. (2003). Social networks: A communication inventory for individuals with complex communication needs and their communication partners-Inventory booklet. Monterey, CA: Augmentative Communication, Inc. Burke, R., Beukelman, D., Ball, L., & Horn, C. (2002). AAC technology learning: Part 1—AAC intervention specialists. Augmentative and Alternative Communication, 18, 242–249. Dalemans, R., de Witte, L., Wade, D., & van den Heuvel, W. (2010). Social participation through the eyes of people with aphasia. International Journal of Language and Communication Disorders, 45, 537–550. doi: 10.3109/13682820903223633 Knowles, M. S., Holton, E. F., & Swanson, R. A. (1998). The adult learner: The definitive classic in adult education and human resource development (5th ed.). Woburn, MA: Butterworth-Heineman. Light, J., Binger, C., & Kelford Smith, A. (1994). Story reading interactions between preschoolers who use AAC and their mothers. Augmentative and Alternative Communication, 10, 255–268.

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Quinn, E., Beukelman, D., & Thiessen, A. (2011). Comparing remote error-free and direct modeling instruction of potential AAC facilitators. Augmentative and Alternative Communication, 20, 97–101. Thiessen, A., & Beukelman, D. (2011, November). Learning styles of potential AAC facilitators. Poster session presented at the American Speech-Language Hearing Association Convention, San Diego, CA.

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A Systems Approach to Training Potential Communication Partners of People With Aphasia Nina Simmons-Mackie Disclosure: Nina Simmons-Mackie has no financial or nonfinancial relationships related to the content of this article.

Abstract Experts have recommended communication partner training as an effective method of improving skills of communication partners and supporting communication of people with aphasia (Simmons-Mackie, Raymer, Armstrong, Holland & Cherney, 2010). Such training involves learning about aphasia, types of communication supports (e.g., low-tech, hightech), and strategies for facilitating communication. Although much of this literature addresses the training of regular, familiar partners, there is evidence that “potential” communication partners can be trained to support communication with unfamiliar people with aphasia (e.g., training health care providers to communicate with patients with aphasia). However, direct training sessions with potential partners does not ensure that partners will implement these support practices in day-to-day activities in organizations such as those associated with health care, government, or business. Rather, experts must take a systems approach if communication support is to be supported by and included in organizational policy and practice. In this article, I describe a systems approach to implementing evidence-based practices in organizations. Successful communication of people with aphasia has been described in terms of “an equation consisting of the skill and experience of the aphasic communicator, the skill and experience of the conversation partner and the availability of appropriate communication resources” (Kagan, 1998, p. 817). The phrase “skill and experience” of both parties includes not only strategies for communicating, but also appropriate knowledge and use of available communication resources such as low-tech or high-tech supports. For example, people with aphasia learn to use gestures, writing, pictographs, or electronic supports; partners also must learn to introduce, use, and model a variety of supports. The communication equation reinforces the importance of the shared communicative responsibility of the communication partner and person with aphasia and serves as an excellent rationale for communication partner training. Moreover, partner training is supported as an “evidence-based” practice. For example, a systematic review of the literature recommended partner training as an effective method of improving skills of partners and supporting communication of people with aphasia (Simmons-Mackie, Raymer, Armstrong, Holland, & Cherney, 2010). Clinicians often think of partner training in relation to familiar partners such as family members, caregivers, or regular attendants. However, a considerable amount of researchers have suggested that potential partners such as volunteers and health care providers can be successfully trained to facilitate and support communication of unfamiliar people with aphasia (Hickey, Bourgeois, & Olswang, 2004; Kagan, Black, Duchan, Simmons-Mackie, & Square,

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2001; Legg, Young, & Bryer 2005; Lyon et al., 1997; Rayner & Marshall, 2003; SimmonsMackie et al., 2007). For example, Legg and colleagues (2005) trained medical students to use communication supports to interview patients with aphasia. Simmons-Mackie and colleagues (2007) studied the outcomes of a Communicative Access Improvement Project (CAIP) that involved 2-day workshops to train stroke teams of 3 health care facilities to support communication of patients with aphasia. The CAIP project also included 4 months of follow-up by a project speech-language pathologist (SLP) who worked with each team to identify and implement individual communicative access goals within their facilities. Welsh and Szabo (2011) reported on a program for training nursing assistant students to support the communication of people with aphasia. The Aphasia Institute in Toronto, Canada has offered training for diverse groups of potential partners such as various health care providers, chaplains, and social workers. Training of health care providers has important implications for changing the communicative accessibility of health care. For example, when health care providers are better able to communicate with people with communication disabilities, these consumers are more likely to participate in their own health care, understand health care information, and make informed decisions. Conversely, poor patient-provider communication is more likely to result in medical mistakes, negative health outcomes, increased health care costs, and poor compliance with recommendations (The Joint Commission, 2010). The argument for improving knowledge and skill of potential communication partners also can be expanded from health care to the community at large. For example, Polovoy (2012) described efforts by the Snyder Center for Aphasia Life Enhancement (SCALE) to create “aphasia-friendly” businesses in Baltimore by improving employee awareness of aphasia and knowledge of methods to support communication of people with aphasia in their establishments. The National Aphasia Association has developed training for first responders (e.g., fire fighters, police) to aid communication with people with aphasia (National Aphasia Association, n.d.). With wider availability of “trained” potential partners to support communication, people with aphasia (and other complex communication needs) are more likely to participate in relevant life situations. Although partner training is often treated as a unitary topic, there are differences in training “potential” unfamiliar partners versus training regular, familiar partners. The specificity of training often differs. Potential partners typically are trained in “generic” strategies and concepts (e.g., “use gestures to supplement speech”), whereas familiar partners often learn both generic and specific individualized strategies and behaviors (e.g., “when Joe’s topic is not clear to you, hold up your hand”). In other words, SLPs can help dyads consisting of a familiar partner and person with aphasia identify specific behaviors that help or get in the way of communicating. Generic training of potential communication partners typically involves learning about aphasia, general characteristics of “good” communication (e.g., taking turns, giving time, showing interest and respect), “typical” strategies (e.g., multimodal communication, verifying understanding), types of supports (e.g., low-tech, high-tech), and use of supports (e.g., role play; Kagan, 1998; Kagan & Gailey, 1993). In addition to learning generic strategies and supports, potential or unfamiliar partners often are taught in groups (e.g., inservice education in hospitals, group workshops, online learning programs). Motivation to learn support methods and change behaviors differs across familiar and potential partners. For example, busy hospital personnel might consider communication with people with a communication disability to be a minor part of their jobs; they often take part in educational programs because it is mandated by policy or superiors. By contrast, family members of people with aphasia often find communication breakdowns an integral part of their daily experience and are motivated to learn ways to communicate with their loved one. Finally, SLPs who are familiar with direct intervention for people with complex communication needs might be unfamiliar with methods of changing system-wide behaviors of large groups (e.g., health care providers in a designated facility). Efforts often involve

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purchasing communication boards and offering inservice education to targeted groups such as stroke unit nursing staff, however, these methods can have disappointing results. In order to ensure that partner training results in actual changes in everyday practice, we likely need to examine a broader approach that addresses system or infrastructure change (Kagan & Leblanc, 2002; Simmons-Mackie et al., 2007).

Knowledge to Practice In spite of the documented effectiveness of partner training (including generic training of unfamiliar, potential partners) and increasing pressure to improve patient-provider communication in health care, there is little evidence of widespread systems changes in communicative access for people with aphasia in the United States. This observation is consistent with the literature that suggests that “evidence-based practice” information tends to be viewed by researchers and scholars, but rarely translated into everyday clinical practice in a timely manner (e.g., Stephens & Upton, 2012). For example, researchers have suggested that there is typically an 8-to-15-year time lag between the time that researchers generate new information and the time that experts actually implement it in health care practice (Dobbins, Ciliska, Cockerill, Rurnsley, & DiCenso, 2002). Because of the limited uptake of research by medical providers and organizations, an entire field called “implementation science” has evolved to aid the translation of innovative, evidence-based research into clinical practice. Research in the area of knowledge translation and implementation can aid SLPs in the quest to improve communicative access for people with communication disabilities and help expand partner training in health care and in the community at large. Focus on “Systems” The partner training literature tends to focus on training of individuals or groups of individuals to support communication of people with communication disabilities. However, individual knowledge and skill is only one piece of the larger communicative access puzzle. The “end goal” of partner training involves facilitating the participation of people with communication disabilities in communication activities (i.e., communication support). Therefore, it is important to focus on how “trained partners” function within a broader system. Factors within the broader social or organizational context significantly influence the uptake of new practices and application of individual knowledge and skills to everyday activities (e.g., Battista, 1989; Dobbins et al., 2002; Kaluzny, 1974; Kaluzny, Veney, & Gentry, 1974). For example, hospital-based SLPs often express frustration because, in spite of inservices to train nursing personnel, staff do not use communication boards or other support tools placed at patient bedsides. One reason is that uptake of trained behaviors is influenced, at least in part, by the hospital or organizational context. Ho and colleagues (2004) describe potential factors that influence the uptake of any “practice” in an organization (see Table 1). For example, management must support a new practice at multiple levels of the organization (an organizational factor) in order for the practice to flourish. In the Communicative Access Improvement Project cited above, investigators found that an important facilitator of practice change involved organizational and managerial support (Simmons-Mackie et al., 2007). Managerial support included managers who worked with teams to achieve practice changes, approved projects, sanctioned time for communication support activities and gave staff positive feedback related to support activities. Staff of a long-term care facility involved in the CAIP project reported that once they were given more time to communicate with patients (logistical factor), the relevance and importance of support became more apparent (cognitive factor). That is, staff found it easier to manage patients and patients reported greater satisfaction with staff or programs when skilled partners supported the communication of patients. By considering the systems factors that influence uptake of communication support practices by potential communication partners, the barriers and facilitators become more apparent. In other words, implementation of practice changes “requires whole system change implicating both the individual and organization” (Kitson et al.,

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2008, p. 2). Piecemeal training of groups of potential communication partners usually is insufficient for effecting sustainable changes in communication support behavior. Rather, we need an approach that involves analyzing what is required at a systems level, identifying probable systemic barriers to implementing communication support, and employing methods of overcoming barriers and facilitating uptake of communication support practices. Table 1. Factors That Influence the Uptake of New Practices or Behaviors By an Organization (Ho et al., 2004) Factors

Examples

Organizational Factors

Policies, management support of a practice, key stakeholders, organizational culture (values, assumptions), decision-making patterns

Financial Factors

Cost to organization of a practice (e.g., increased staff time), current and/or future cost savings (e.g., shorter length of stay)

Legal Issues

Liability, pressure from relevant legislation and policy (e.g., Americans with Disabilities Act, Joint Commission guidelines)

Ethical Issues

Confidentiality, consent (e.g., who decides if patient is competent to make decisions given communication support)

Professional Factors

Professional standards, professional training requirements (e.g., required continuing professional education)

Individual User Factors

Individual knowledge and training; culture (e.g., professional & individual culture); values, attitudes, interests, & beliefs

Logistical Factors

Workflow, time, physical access to resources, sustainability of practices

Cognitive Factors

Meaningfulness, relevance, reward value of a practice

Engage Key Stakeholders In order to train potential communication partners, one must identify people who should be trained. However, it also is necessary to identify key “stakeholders” who will influence the day-to-day practices that will be taught. In other words, a training program must take into account the influence of multiple stakeholders on actual implementation of communication support. For example, in health care settings there are obvious groups that might be included in partner training, such as nursing and therapy staff. There are also less obvious potential partners that could make a difference in a patient’s experience with a facility or business. Telephone operators, receptionists, and parking attendants often are the first interface of an organization with someone with a communication disability; implementing communication support strategies by these front line personnel could be an important aspect of services. Administrators and managers might not offer direct communication support to people with aphasia; however, they strongly influence the uptake of behavioral changes by their personnel. Consumers and their loved ones also are key stakeholders in the process; understanding consumer demographics, needs, and wants is important in developing appropriate partner training packages and ensuring implementation across a system or organization. Employ Strategies That Effect Change In order to work towards the end goal of improved communicative interactions between people with communication disabilities and communication partners, it helps to consider stages associated with behavior change (e.g., Prochaska & DiClemente, 1983; Sherman & Carothers, 2005). A first stage for many potential partners and for other stakeholders involved in practice change is “poor awareness” and lack of knowledge. This stage is characterized by a lack of awareness of new technologies and lack of awareness of evidence-based practices. Relative to partner training in particular, this stage relates to potential partners who have no knowledge of aphasia, understanding of the communication consequences of aphasia, or

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awareness of communication support and augmentative communication tools and strategies. The target of intervention for individuals at this stage is fairly straightforward: to raise awareness of and understanding of the disorder and communication supports. Awareness campaigns often involve written materials, educational modules, or online learning packages. Potential partners and other stakeholders at Stage 2 are aware of an issue (e.g., aphasia, communication breakdown) or a new practice (e.g., communication support), but may not appreciate that they need to change their own behavior or organizational practices. When someone learns about an issue, he or she forms attitudes, including beliefs about how the knowledge relates to oneself or one’s organization. For example, health care providers might learn about communication disabilities such as aphasia, but fail to recognize their own contribution to communication failures (because of lack of skill in communication support). Instead, they tend to view the problem as residing in the person with the disability, not in their own lack of skill in supporting communication. Administrators might consider communicative access programs involving partner training to be superfluous or tangential to institutional missions. In order to effect changes in practices at this stage, experts must identify potential barriers and “persuade” stakeholders (Dobbins et al., 2002). Therefore, it is important to establish the importance and relevance of trained partners and communicative access. One could argue for the importance of partner training and communicative access from many perspectives, such as the potential for altruistic rewards (e.g., helping others), financial rewards (e.g., increasing sales in a business, reducing critical incidents in hospitals), or official rewards (e.g., accreditation, avoiding malpractice, conforming to laws). For example, health care administrators and policy makers are more likely to consider partner training relevant when it is presented within the broader context of “effective patient-provider communication” consistent with Joint Commission guidelines (Joint Commission, 2010); thus, promoting communication support is situated within requirements for health literacy and communicative access. When spearheading a system-wide change, one should clearly articulate the potential rewards if employee buy-in is expected. In addition, one should identify both potential barriers to implementation and methods of reducing these barriers. In Table 2, I provide examples of potential barriers to implementing communication supports in health care environments.

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Table 2. Potential Barriers to Implementing Communication Supports by Trained Partners in Health Care Settings (Grol & Grimshaw, 2003). Type of Barrier

Examples of Barrier

Examples of Solutions

Work Environment

•

Lack of time

•

•

Too many responsibilities already

•

Limited access to resources (e.g., support materials, technology)

Establish policy that requires altered workload when person with communication disability is on caseload

•

Involve management in identifying solutions

•

Workflow/routines do not accommodate changes

•

•

Added work with no added incentives

SLP and administration work together to establish a plan and funding for program specific resources

•

Unclear assignment of duties

•

Develop incentives for “good” communication support

•

Lack of knowledge and skill regarding AAC

•

Institute partner training programs

•

No one to help with implementation

•

•

Negative attitudes or beliefs

•

Fear of failure or complaints

Identify communication support liaison to provide ongoing consultation and help to staff

•

Lack of confidence

•

•

Unsuccessful experiences with AAC

Pair new partners with experienced partners to deliver appropriate support and gain confidence

•

Involve staff in identifying solutions

Individual factors

Social Context

•

Superiors lack knowledge and skill regarding AAC

•

Training sessions for management

•

Lack of support of superiors

•

•

Lack of “opinion leaders” to change perceptions

System for monitoring communication support and providing helpful feedback

•

Lack of timely feedback

•

•

Negative feedback

Involve management in identifying solutions

Stage 3 involves stakeholder recognition of the problem, decisions about implementing changes, and development of strategies to change behavior. For example, a hospital administrator or manager might acknowledge the need to improve communication with individuals with communication disability and organize a task force to address the need. The plan might include policy changes, fiscal allocations, staff training, logistical support (e.g., additional time built into tasks with communication disabled individuals), and a system for rewarding successful implementation or identifying problems. At this stage, the hospital would undertake traditional generic partner training of targeted groups of potential communication partners. This might involve workshops, online training modules, or a variety of other delivery options. However, continuing education activities such as inservice education, workshops, training modules, or written materials promote the acquisition of explicit knowledge, but this type of learning typically does not help people translate the knowledge into clinical practice (Davis et al., 1999; Thomson-Obrien et al., 2004). These “one-way” methods of transferring knowledge have been referred to as “push” tactics in which information is pushed at potential users. Such methods often fail to effect changes in day-to-day behavior (Bero et al., 1998).

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Rather, a two-way process is required, in which key stakeholders are involved not only in learning, but also in creating ways to integrate knowledge into work settings. In other words, the process of learning should be interactive and creative (Kagan, Simmons-Mackie, Gibson, Conklin, & Elman, 2010). This requires engaging key stakeholders in the process of identifying goals, practice parameters, and implementation strategies, rather than providing generic information and expecting them to apply the skills to their own practices. Potential partners might take part in a basic training on communication support and then participate in problemsolving about applications of communication support that are relevant in their own setting. This might involve identifying personal or organizational goals, barriers, and implementation strategies and ensuring that the system supports the implementation of skills. When an organization undertakes this type of interactive approach to learning, the active learners better understand how to apply knowledge within their own settings, feel more invested in outcomes, and help solve potential implementation barriers. Stage 4 involves “knowledge to action,” in which potential communication partners employ learned skills within their day-to-day interactions with people with communication problems. At this stage, it is critical that the organization conducts some form of evaluation to ensure that changes are taking place and that the effects are successful and positive. Evaluation, feedback, and audit are powerful mechanisms for ensuring that day-to-day practices are actually changing. Evaluation might take several forms, including assessment of knowledge acquisition (e.g., pre- and post-knowledge quiz, survey), evaluation of staff performance (audits of behavior change, observation, job effectiveness study), assessment of satisfaction (e.g., staff or consumer satisfaction survey), and evaluation of systems change (e.g., policy audit, cost savings, quality assurance). In a study of implementation of clinical practice guidelines in health care, investigators found that the most useful methods of implementing evidence-based practices or promoting knowledge to action among providers was “timely, individualized, non-punitive feedback” (Hysong, Best, & Pugh, 2006). For example, the SLP might work alongside nursing staff and observe patient-provider interactions on a nursing unit to determine if trained strategies are being implemented and offer staff immediate, positive feedback or help in implementing supports. Obviously, this example assumes that administrative support has been provided for SLP time to be allocated to implementation strategies. Although they are not individualized and timely, one also could use surveys to gather program data about the outcomes of partner training. This type of information is useful for global program evaluation and quality assurance. The final phase of practice implementation involves monitoring and maintaining practices over time. Organizational policies that establish the value of communication support and ensure ongoing training and implementation are necessary. A workplace needs administrative support in order to create an institutional culture that values communication support and provides necessary time, funding, and reward for implementation. In other words, the system reinforces continuing attention to creating and maintaining an environment where communication partner training is ongoing and where implementing communication support as an integral practice is reinforced. In effect, communication support becomes an integral aspect of practice, much like infection control in health care. At this stage, evaluation and audit procedures are continued in an effort to determine if practices are being maintained and if the practices are contributing to improved communication of people with communication disabilities. SLPs with knowledge and experience in augmentative and alternative communication and communication support can play a key role in improving communicative access for people with communication disabilities, such as aphasia. However, training potential partners of people with communication disabilities is only one part of the broader goal of increasing communicative access to and participation in the community. If the broader goal of communication access is to be achieved, then partner training should be situated within a systems-wide approach to changing communicative support practices of organizations. Based

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on this conception, we might expand the communication equation introduced at the beginning of this article: successful communication of people with aphasia in health care or other community settings entails “the skill and experience of the aphasic communicator, the skill and experience of the conversation partner and the availability of appropriate communication resources” (Kagan, 1998, p. 817) and an organizational and social context that values and encourages supported communication. The systems-wide innovations discussed in this article require a knowledgeable and committed SLP. The suggestions also require a significant organizational commitment to appropriate policy, adequate staffing, and sufficient funding to support successful implementation of communication supports. Such collaboration between SLPs and organizations can help create environments where people with aphasia or other communication disabilities are respected and supported.

References Battista, R. N. (1989). Innovation and diffusion of health-related technologies. A conceptual framework. International Journal of’ Technology Assessment in Health Care, 5(2), 227–248. Bero, L. A., Grilli, R., Grimshaw, J. M., Harvey, E., Oxman, A. D., & Thomson, M. A. (1998). Getting research findings into practice: An overview of systematic reviews of interventions to promote the implementation of research findings. British Medical Journal, 317(15), 465–468. Davis, D., O’Brien, M., Freemantle, N., Wolf, F., Mazmanian, P., & Taylor-Vaisey, A. (1999). Impact of formal CME: Do conferences, workshops, rounds and other CE activities change physician behavior or health care outcomes? Journal of the American Medical Association, 282(9), 867–874. Dobbins, M., Ciliska, D., Cockerill, R., Rurnsley, J., & DiCenso, U. (2002). A framework for the dissemination and utilization of research for healthcare policy and practice. The Online Journal of Knowledge Synthesis for Nursing, 9(7). Grol, R., & Grimshaw, J. (2003). From best evidence to best practice: Effective implementation of change in patients’ care. Lancet, 362, 1225–1230. Hickey E., Bourgeois, M., & Olswang, L. (2004). Effects of training volunteers to converse with nursing home residents with aphasia. Aphasiology, 18, 625–637. Ho, K, Bloch, R., Gondocz, T., Laprise, R., Perrier, L., Ryan,D., … Wenghofer,E. (2004). Technologyenabled knowledge translation: Frameworks to promote research and practice. The Journal of Continuing Education in the Health Professions, 24, 90–99. Hysong, S., Best, R., & Pugh, J. (2006). Audit and feedback and clinical practice guideline adherence: Making feedback actionable. Implementation Science, 1(9), 1–10. Kagan, A. (1998). Supported conversation for adults with aphasia: Methods and resources for training conversation partners. Aphasiology, 12, 816–30. Kagan, A., Black, S., Duchan, J., Simmons-Mackie, N., & Square, P. (2001). Training volunteers as conversation partners using "Supported Conversation for Adults with Aphasia" (SCA): A controlled trial. Journal of Speech, Language & Hearing Research, 44, 624–638. Kagan, A., & LeBlanc, K. (2002). Motivating for infrastructure change: Toward a communicatively accessible, participation-based stroke care system for all those affected by aphasia. Journal of Communication Disorders, 35(2), 153–169. Kagan, A., & Gailey, G. (1993) Functional is not enough: Training conversation partners for aphasic adults. In A. Holland & M. Forbes (Eds.). Aphasia treatment: World perspectives (pp 199–225). San Diego, CA: Singular. Kagan, A, Simmons-Mackie, N., Gibson, J., Conklin, J., & Elman, R. (2010). Closing the evidence, research, and practice loop: Examples of knowledge transfer and exchange from the field of aphasia. Aphasiology, 24, 535–548, Kaluzny, A. (1974). Innovation in health services: Theoretical framework and review of research. Health Services Research, 9(2), 101–120. Kaluzny, A., Veney, J., & Gentry, J. (1974). Innovation of health services: A comparative study of hospitals and health departments. Mllbank Memorial Fund Quarterly/Health and Society, 52(1), 51–82.

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Kitson, A. L., Rycroft-Malone, J., Harvey, G., McCormack, B., Seers, K., & Titchen, A. (2008). Evaluating the successful implementation of evidence into practice using the PARiHS framework: Theoretical and practical challenges. Implementation Science, 3(1), 1–12. Legg, C., Young, L., & Bryer, A. (2005). Training sixth-year medical students in obtaining case-history information from adults with aphasia. Aphasiology, 19, 559–575. Lyon, J., Cariski, D., Keisler, L., Rosenbek, J., Levine, R., Kumpula, J., … Blanc, M. (1997). Communication Partners: Enhancing participation in life and communication for adults with aphasia in natural settings. Aphasiology, 11, 693–708. National Aphasia Association. (n.d.). NAA emergency responder training. Retrieved from http://www.aphasia.org/EmergencyResponder.html Polovoy, C. (2002, February 14). Baltimore's "aphasia-friendly" businesses. ASHA Leader. Retrieved from http://www.asha.org/Publications Prochaska, J., & DiClemente, C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 390–395. Rayner, H., & Marshall, J. (2003). Training volunteers as conversation partners for people with aphasia. International Journal of Language and Communication Disorders, 38, 149–64. Sherman, M., & Carothers, R. (2005). Applying the readiness to change model to implementation of family intervention for serious mental illness. Community Mental Health Journal, 41(2), 115–127. Simmons-Mackie, N., Kagan, A., Christie, C., Huijbregts, M., McEwen, S. & Willems, J. (2007). Communicative access and decision making for people with aphasia: Implementing sustainable healthcare systems change. Aphasiology, 21, 39–66. Simmons-Mackie, N., Raymer, S., Armstrong, E., Holland, A., & Cherney, L. (2010). Partner training in aphasia: A systematic review. Archives of Physical Medicine and Rehabilitation, 91, 1814–1837. Stephens, D., & Upton, D. (2012). Speech and language therapist’s understanding and adoption of evidence based practice. International Journal of Therapy and Rehabilitation, 19(6), 328–334. The Joint Commission. (2010). Advancing effective communication, cultural competence, and patient- and family-centered care: A roadmap for hospitals. Oakbrook Terrace, IL: The Joint Commission. Retrieved from http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf Thomson-O’Brien, M., Freemantle, N., Oxman, A. D., Wolf, F., Davis, D., & Herrin, J. (2004). Continuing education meetings and workshops: Effects on professional practice and health care outcomes (Cochrane Review). The Cochrane Library, Issue 4. Chichester, UK: Wiley & Sons. Welsh, J., & Szabo, G. (2011). Teaching nursing assistant students about aphasia and communication. Seminars in Speech and Language,32(3), 243–255.

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AAC and Communication in the Workplace David McNaughton Department of Educational Psychology, Counseling, and Special Education Department of Communication Sciences and Disorders, The Pennsylvania State University

David Chapple The Prentke-Romich Company Disclosure: David McNaughton has no financial or nonfinancial relationships related to the content of this article. Disclosure: David Chapple has no financial or nonfinancial relationships related to the content of this article.

Abstract Communication in the workplace holds many challenges for persons with complex communication needs. A better understanding of workplace communication, and the use of evidence-based strategies for supporting workplace communication by persons who use AAC, can result in improved employment outcomes. Employment is a goal of many individuals who use AAC (Bryen, Potts, & Carey, 2007; McNaughton, Arnold, Sennott, & Serpentine, 2010; Pugh & Capilouto, 2009). To support positive employment outcomes for individuals who use AAC, we need a better understanding of the communication demands of the workplace, and transition strategies to prepare individuals who use AAC for employment (McNaughton, Bryen, Blackstone, Williams, & Kennedy, 2012). In an effort to provide a variety of perspectives on AAC and communication in the workplace, this paper is co-written by David McNaughton, a university-based researcher on the topic of employment and AAC, and David Chapple, an expert user of AAC technologies and the editor for AAC ConsumerNet. David Chapple currently uses an Eco 2 to communicate, and controls his device using a tracker dot attached to his glasses. He has published extensively on his educational and employment activities (Chapple, 2000, 2011; Chapple & Moats, 2001; McNaughton & Chapple, 2012), and his personal insights will be used to illustrate the major themes of this text. In this paper, we address five key aspects features of communication in the workplace: the content “rich” nature of workplace communication, the speed of interaction at the worksite, the use of a variety of communication modes in employment settings, the mixture of formal and informal communication that takes place with co-workers, and the range of familiar and unfamiliar communication partners that will be encountered by workers who use AAC. We also will provide suggestions regarding educational experiences and communication supports that can enhance the employment experiences of individuals who use AAC.

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Content Rich Vocabulary Individuals who use AAC are employed in a wide range of jobs (McNaughton & Bryen, 2007). Although there is some vocabulary that is generic across a variety of communication domains (Collier, 2000), specific jobs also have accompanying vocabulary that will be critical to the individual’s ability to effectively function and be viewed as a co-worker in a specific setting (Creech, 1993). The ability to demonstrate proficient use of needed vocabulary is important not only in the workplace, but during the job search process as well. In searching for a job, David Chapple sent out letters of application with detailed information about his education and work experiences along with a resume. Once he had scheduled an interview, he then shared information on his use of assistive technology and AAC and described the workplace modifications that he used to complete work activities. As David describes below, during the interview it was his ability to use the language of the workplace to keep the focus of the interview on his skills, rather than on the physical challenges he might experience in the workplace, that earned him his job. One day in September I received an e-mail from Wayne Largent from a company named CyberAccess asking me if I wanted an interview. Thinking I wouldn’t get the job anyways, I wrote him back a description detailing my disability and the AAC device I used at that time, a Liberator; I even sent him my web site that has my picture on it. After all this I really didn’t expect an interview, but in a couple of days I received a call to set up an interview [...] The person that finally hired me saw my skills instead of my disability. He also said he liked how I made him feel comfortable with my disability by just being myself and not letting it be the focus of the interview or any conversation. If anybody asks about my disability, as it was the case during the interview, I answer them and move on. Success in the workplace will depend not only on participation in work-related discussions, but also the ability to participate in social interactions. Coworkers frequently interact about non-work related topics, such as sports, current events, and leisure activities (Mautz, Storey, & Certo, 2001), and between 35% and 90% of time in the workplace is spent in interaction with others (Henderson & Argyle, 1985). Balandin and Iacono (1999) examined meal-break conversations for 34 individuals without disabilities, and found that a core of 347 words accounted for 78% of the conversation. At the same time, a large fringe vocabulary, containing many unique words, served to communicate the key ideas in the conversation and to express individuality. Access to these vocabulary items, including “slang” terms, is key to establishing membership in the workplace. As Rick Creech, an individual who uses AAC and who was a long-term employee in the Pennsylvania Department of Education noted, “the workplace requires an expanded vocabulary because in the workplace employees use words that they do not use anywhere else” (Creech, 1993, p. 105). Literacy also often plays a key role in supporting the ability of the individual to communicate in the workplace. Literacy is not a requirement for the employment of individuals who use AAC, as Light, Stoltz, and McNaughton (1993) reported that roughly half of the individuals using AAC who participated in their employment survey had reading skills below a Grade 3 level. However, many of these individuals were involved in manual labor jobs that may not be an option for persons with more severe disabilities. Also, those individuals with the lowest levels of literacy skills were the individuals who expressed the lowest levels of satisfaction with their jobs, perhaps because they also reported the lowest chances of promotion in their job settings.

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Communication Speed In the workplace, as in many communication environments, there are times when speed of communication is critical (McNaughton, Light, & Gulla, 2003). As Wisenburn and Higginbotham (2009) noted, “By increasing the expressive communication rate of AAC, people who use these systems may produce more relevant and timely statements, provide a more positive impression to their communication partners, and increase opportunities for engaging interactions,” (p. 78). Researchers have suggested a variety of approaches to increase the speed of communication for persons who use of AAC (Higginbotham, Lesher, Moulton, & Roark, 2012). One common approach is to anticipate some of the more commonly used vocabulary items and to preprogram them into the device. As David Chapple explains below, this can be a very effective technique in occupations such as computer programming in which some of the vocabulary can be anticipated. The true expertise of the position lies in knowing which vocabulary to use when! When I got the job there was little question that I was qualified, but there was an issue about my speed. […] I had previously had some experience with programming for a very small computer company on a very part-time basis, but I just got two assignments in a year. During that time I stored a lot of the most common programming commands under icon sequences, which makes me a relatively fast programmer, so I did get something out of that job experience. However, some of the programming commands are a part of everyday language and therefore are already stored in my AAC device. Some examples are the “if-then-else” statement, the “do-while” statement and the “fornext” statements. Wayne, my boss at CyberTech, was very impressed with how much I could do in a week. When I first started he thought my speed would be a problem, but he took a chance on me anyway. His worries quickly diminished. He discovered my work output equaled that of a programmer without disabilities! Although there clearly are times when speed is a critical issue, at present we have a limited understanding of the relative importance of different interaction characteristics in a conversation (Beukelman & Mirenda, 2013; Light, 1988), and how listeners conceptualize trade-offs between rate and relevance (i.e., quality of information) during an interaction (Wisenburn & Higginbotham, 2009). For example, although communication partners can become frustrated with slow rates of conversation in some situations (McNaughton & Bryen, 2007), there is informal evidence that callers to a help line for assistive technology accept a slightly lower rate of communication in other situations in which a variety of goals are relevant, for example, in order to obtain technical support for an AAC device from a person who is himself or herself a user of AAC (McNaughton & Arnold, 2010, 2011). Critical to the successful use of the AAC device to support communication in the workplace is the provision of appropriate education supports prior to transition to the workplace. As Randy Horton, himself a user of AAC technology, observed, basic training in the use of the AAC device rarely is provided to the user prior to expected use (Horton, Horton, & Meyers, 2001). In fact, in a survey of individuals who use AAC and were seeking employment, Pugh and Capilouto (2009) noted that 80% of the respondents indicated that they were not even introduced to the use of AAC until after the age of 12. Although researchers have demonstrated that introducing supports for communication and literacy at an early age has a strong positive impact for individuals with complex communication needs (Light & McNaughton, 2012), there also have been promising results for programs that intervene with adolescents and young adults as they transition to the adult world. The Augmentative Communication and Empowerment Supports program (Bryen, Slesaransky, & Baker, 1995) provided adults with significant physical and speech disabilities with training in the use of their AAC devices. Seventeen adults with significant physical and

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speech disabilities participated in the 2-week immersion program and 1 year of follow-up training and support. Most participants reported that the instruction in their use of an AAC device had substantially helped them in a variety of major life activities, including communicating with unfamiliar people and maintaining a source of income. The Augmentative Communication Employment Training and Supports program focused on strategies for obtaining employment (Bryen, Cohen, & Carey, 2004). The 5-day training (and 1 year of on-line coaching) resulted in participant reports of improved job-hunting skills, communication skills, and information technology skills.

Multi-modal Communication Full participation in 21st-century life requires access to a variety of communication technologies (Rideout, Foehr, & Roberts, 2010). Individuals who use AAC always have faced the challenge of how to integrate the effective use of a variety of modes of communication, of making decisions about when and how to use different AAC devices, speech, gestures, and signs as a method of communication (Williams, Krezman, & McNaughton, 2008). Into this mix now comes the many different types of distance communication technologies, for example texting, e-mail, blogging, and video that are common in our everyday world (Sellwood, Wood, & Raghavendra, 2012). In many ways, these new technologies bring new opportunities, as some of the technologies that have now become an accepted part of the workplace (e.g., email, cloud-based document management) may offer advantages over face-to-face communication for individuals with complex communication needs. David Chapple describes how he uses e-mail and instant messaging to communicate in the workplace. With every job I ever had I have had to write daily reports on what work I have done and write detailed descriptions of bugs I found during beta testing. With my device I can type those reports quickly and I am able to use the appropriate words without spelling too much. In addition to the reports, I communicate with the people in the office primarily by e-mail and instant messages. This is true because I mostly work from my house and go to the office for meetings and special events. I can type long and detailed e-mails to my boss or another engineer with whom I may be working with on a project. For some individuals who use AAC, the availability of distance communication technologies makes telework an attractive option. By working from home, these individuals can make use of both adapted technologies and personal supports that may be difficult to arrange in the workplace. McNaughton, Rackensperger, Dorn, and Wilson (2013) describe the work experiences of nine individuals who use AAC to participate in telework activities. Telework was a valued employment strategy for persons who had experienced difficulty in arranging transportation to the workplace and were frustrated with the challenges of arranging transportation and obtaining support for activities of daily living (e.g., assistance at mealtimes) in the workplace. Participants expressed some concerns, including the potential dangers of social isolation and the need for the employer to facilitate the integration of the person who uses AAC into the work and social networks of the organization. An employer should take care to ensure that telework is a choice from a variety of options, not a fallback measure because of inadequate societal support for onsite workplace participation (Baker, Moon, & Ward, 2006).

Mixture of Formal and Informal Communication Success in the workplace depends not only on the ability to complete the required job duties, but also to participate in the wide range of communication and social activities that are seen in the workplace (Storey, 2007). David Chapple describes the unpredictability of some of these communication events and the importance of being able to communicate in flexible and creative ways.

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One of the most important things at CyberAccess is whether or not a potential employee will fit in with the workplace personality. With my VOCA, I can contribute in meetings as well as make an occasional joke with my co-workers. An example of this was at the Christmas party when the company usually provides a movie. One year the VCR was broken and nobody knew what to do. I suggested that I could sing Christmas carols. Everybody thought that was very funny and they still talk about it to this day. Another example is when groups of employees had to do skits during a training exercise about a certain situation that happened in the daily operations of the company. This turned into a big satire of those situations and that was the purpose I believe. I was able to take part in my group’s skit because I was able to save my lines and recite them on cue. This was very fun for me and I think my co-workers enjoyed my participation. Developing opportunities to participate in part-time and summer employment activities helps individual who use AAC develop needed communication skills, and can alert parents and teachers to needed areas of development for the student’s academic curriculum (Carter, Austin, & Trainor, 2012). These early experiences also provide an important time to learn the “soft skills” of time-management, problem-solving, and fitting in with work-place culture that will be critical to successful employment (Bryen et al., 2007).

Communicating with familiar and unfamiliar partners Successful communication requires skills from both sides of the conversation; sometimes, however, individuals who use AAC will need to take the lead in introducing their method of communication to persons who have previously had limited experience with persons who use AAC. In many cases, there are both knowledge and social barriers that must be overcome. Jim Prentice (2000), an individual who used AAC and worked at a large corporation for a number of years, describes the tactics he used to introduce himself to his coworkers during his first days at the new job. When I started to work, I’m sure that all the employees surrounding my workstation probably thought I was someone from Mars. I rode in on my motorized wheelchair and had some sort of device attached to my chair. I rode past them, and they really didn’t know whether I was able to talk. If they did talk to me, they weren’t sure I was able to answer them. They never saw someone coming to their work with a communicator. I stopped them in their tracks, before they were frozen on the spot, and said, “Good morning, my name is Jim. How are all of you doing today?” Big smiles came on their faces, and they seemed to answer in unison, “We are fine, and it’s nice to have you working with us.” That sure broke the ice, I felt like one of the team then. I made sure I programmed a few jokes into my communicator so that it would make my conversations more friendly and comfortable for them. It worked! There are a variety of strategies individuals or companies can use to support individuals who use AAC in learning the skills needed to successfully engage in communicative interaction with familiar and unfamiliar partners. For example, Light, Binger, Agate, and Ramsey (1999) described strategies for teaching partner-focused questions to individuals who use AAC and the positive impact of the use of these strategies on the perceptions of communication partners.

Summary Obtaining and maintaining employment provides many challenges both for the individual who uses AAC and for the individuals who support them. At the same time, there now is growing evidence that employment is a viable goal for persons with complex communication needs (McNaughton et al., 2010, 2012). When employers and individuals pay careful attention to addressing the challenges of workplace communication and the provision of

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a variety of key education and employment transition activities, they help to promote success for persons who use AAC in the workplace.

References Baker, P. M. A., Moon, N. W., & Ward, A. C. (2006). Virtual exclusion and telework: Barriers and opportunities of technocentric workplace accommodation policy. Work: A Journal of Prevention, Assessment and Rehabilitation, 27, 421–430. Balandin, S., & Iacono, T. (1999). Crews, wusses, and whoppas: Core and fringe vocabularies of Australian meal-break conversations in the workplace. Augmentative and Alternative Communication, 15, 95–109. doi:10.1080/07434619912331278605 Beukelman, D., & Mirenda, P. (2013). Augmentative and Alternative Communication (4th ed.). Baltimore, MD: Paul H. Brookes. Bryen, D. N., Cohen, K. J., & Carey, A. (2004). Augmentative communication employment training and supports (ACETS): Some employment-related outcomes. Journal of Rehabilitation, 70(1), 10–18 Bryen, D. N., Potts, B. B., & Carey, A. C. (2007). So you want to work? What employers say about job skills, recruitment and hiring employees who rely on AAC. Augmentative and Alternative Communication, 23, 126–139. Bryen, D. N., Slesaransky, G., & Baker, D. B. (1995). Augmentative communication and empowerment supports: A look at outcomes. Augmentative and Alternative Communication, 11, 79–88. Carter, E. W., Austin, D., & Trainor, A. A. (2012). Predictors of postschool employment outcomes for young adults with severe disabilities. Journal of Disability Policy Studies, 23, 50–63. Chapple, D. (2000). Empowerment. In M. Fried-Oken & H. Bersani (Eds.) Speaking up and spelling it out: Personal essays on augmentative communication (pp. 153–160). Baltimore, MD: Paul H. Brookes. Chapple, D. (2011). The evolution of augmentative communication and the importance of alternate access. Perspectives on Augmentative and Alternative Communication, 20, 34–37. Chapple, D. (2011). Communication in the hospital. Retrieved from http://www.aacinstitute.org/AACConsumerNet/AroundTheWaterCooler/2011June.html Chapple, D., & Moats, M. (2001). Changing jobs, keeping personal care attendants. In R. V. Conti & C. Jenkins-Odorisio (Eds.), Proceedings of the Pittsburgh Employment Conference for Augmentated Communicators (pp. 4–6). Pittsburgh, PA: SHOUT Press. Collier, B. (2000). See what we say: Situational vocabulary for adults who use AAC. Baltimore, MD: Paul H. Brookes. Creech, R. (1993). Productive employment for augmented communicators. In R. V. Conti & C. JenkinsOdorisio (Eds.), Proceedings of the First Annual Pittsburgh Employment Conference for Augmented Communicators (pp. 105–108). Pittsburgh, PA: SHOUT Press. Henderson, M., & Argyle, M. (1985). Social support for four categories of work colleague: Relationship between activities, stress, and satisfaction. Journal of Occupational Behavior, 6, 229–239. Higginbotham, D. J., Lesher, G. W., Moulton, B. J., & Roark, B. (2012). The application of Natural Language Processing to augmentative and alternative communication. Assistive Technology, 24, 14–24. doi:10.1080/10400435.2011.648714 Horton, R., Horton, K., & Meyers, L. (2001). Getting the literacy and language skills needed for employment: Teaching is the solution. (pp. 46–51). In R. V. Conti, P. Meneskie, & C. Micher (Eds.), Proceedings of the Eighth Pittsburgh Employment Conference for Augmented Communicators, Pittsburgh, PA: SHOUT Press. Light, J. (1988). Interaction involving individuals using augmentative and alternative communication systems: State of the art and future directions. Augmentative and Alternative Communication, 4, 66–82. doi:10.1080/07434618812331274657 Light, J. C., Binger, C., Agate, T. L., & Ramsay, K. N. (1999). Teaching partner-focused questions to individuals who use augmentative and alternative communication to enhance their communicative competence. Journal of Speech, Language, and Hearing Research, 42, 241–255.

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Light, J., & McNaughton, D. (2012). Supporting the communication, language, and literacy development of children with complex communication needs: State of the science and future research priorities. Assistive Technology, 24, 34–44. doi:10.1080/10400435.2011.648717 Light, J., Stoltz, B., & McNaughton, D. (1996). Community-based employment: Experiences of adults who use AAC. Augmentative & Alternative Communication, 12, 215–229. Mautz, D., Storey, K., & Certo, N. (2001). Increasing integrated workplace social interactions: The effects of job modification, natural supports, adaptive communication instruction, and job coach training. Journal of the Association for Persons with Severe Handicaps, 26, 257–269. McNaughton, D., & Arnold, A. (2010). Supporting positive employment outcomes for individuals who use AAC. Perspectives on Augmentative and Alternative Communication, 19, 51–59. McNaughton, D., & Arnold, A. (2011). Employment and individuals who use AAC. Retrieved from http://aac-rerc.psu.edu/index.php/webcasts/show/id/15 McNaughton, D., & Bryen, D. (2007). AAC technologies to enhance participation and access to meaningful societal roles for adolescents and adults with developmental disabilities who require AAC. Augmentative and Alternative Communication, 23, 217–229. McNaughton, D., & Chapple, D. (2012, June). AAC in the workplace. Presented at the ASHA AAC SIG Conference: Partner Instruction in AAC: Strategies for Building Circles of Support. Retrieved from http://aac-rerc.psu.edu/index.php/webcasts/show/id/31 McNaughton, D., Light, J., & Gulla, S. (2003). Opening up a “whole new world”: Employer and co-worker perspectives on working with individuals who use augmentative and alternative communication. Augmentative and Alternative Communication, 19, 235–253. McNaughton, D., Rackensperger, T., Dorn, D., & Wilson, N. (2013). “Home is at work and work is at home”: Telework and individuals who use augmentative and alternative communication. Manuscript submitted for publication. McNaughton, D. B., Arnold, A., Sennott, S., & Serpentine, E. (2010). Developing skills, “Making a match”, and obtaining needed supports: Successful employment for individuals who use AAC. In D. McNaughton & D. Beukelman (Eds.) Transition strategies for adolescents and young adults who use AAC (pp. 111–127). Baltimore, MD: Paul H. Brookes. McNaughton, D. B., Bryen, D. N., Blackstone, S. W., Williams, M. B., & Kennedy, P. (2012). Young adults with complex communication needs: Research and development in AAC for a “Diverse” population. Assistive Technology, 24(1), 45–53. Prentice, J. (2000). With communication, anything is possible. In M. Fried-Oken & H. A. Bersani (Eds.) Speaking up and spelling it out. (pp. 207–214). Baltimore, MD: Paul H. Brookes. Pugh, B., & Capilouto, G. (2009, October). Employment survey of individuals who use augmentative and alternative communication. Presented at the 2009 Clinical AAC Research Conference, Pittsburgh, PA. Rideout, V. J., Foehr, U. G., & Roberts, D. F. (2010). Generation M2 - Media in the lives of 8–18 year olds. Kaiser Foundation. Retrieved from www.kff.org/entmedia/upload/8010.pdf Sellwood, D., Wood, D., & Raghavendra, P. (2012). Perspectives on the telecommunications access methods of people with complex communication needs. Telecommunications Journal of Australia, 62(2). doi:10.7790/tja.v62i2.295 Storey, K. (2007). Review of research on self-management interventions in supported employment settings for employees with disabilities. Career Development for Exceptional Individuals. 30, 27–34. Williams, M. B., Krezman, C., & McNaughton, D. (2008). “Reach for the stars”: Five principles for the next 25 years of AAC. Augmentative and Alternative Communication, 24, 194–206. Wisenburn, B., & Higginbotham, D. J. (2009). Participant evaluations of rate and communication efficacy of an AAC application using Natural Language Processing. Augmentative and Alternative Communication, 25, 78–89. doi:10.1080/07434610902739876

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Enhanced Milieu Teaching: Incorporating AAC Into Naturalistic Teaching With Young Children and Their Partners Ann Kaiser Courtney Wright Department of Special Education, Vanderbilt University Nashville, TN Disclosure: Ann Kaiser has no financial or nonfinancial relationships related to the content of this article. Disclosure: Courtney Wright has no financial or nonfinancial relationships related to the content of this article.

Abstract Enhanced Milieu Teaching (EMT) is an evidence-based naturalistic intervention strategy that teaches functional communication and language skills in everyday interactions with partners. In this manuscript, we describe the of the key communication support strategies used in EMT and how individuals can use these strategies with augmentative and alternative communication systems. We also present strategies for teaching partners to use EMT with AAC in interactions with young children. Enhanced Milieu Teaching (EMT) is a naturalistic communication intervention that combines elements of responsive interaction with systematic modeling and prompting to promote spontaneous, functional communication. The foundational strategies of EMT derive from both behavioral and developmental principles to teaching communication to young children (Hancock & Kaiser, 2002). EMT strategies include following the child’s lead in conversation and play, responding to communicative initiations from the child with target language, expanding child utterances by adding words to increase complexity while maintaining the child’s meanings, arranging the environment to support and elicit communication from the child, and using systematic milieu teaching prompts. EMT is based on two key premises, that communication is learned in the context of interactions with partners and that when partners use effective behavioral and developmental strategies for teaching and supporting child communication, children can learn functional and elaborated language and communication skills in the context of everyday interactions. Researchers in more than 30 studies have examined the effects of EMT. Researchers have shown EMT to produce increases in communication skills for young children with significant communication impairments including children with language delays (Hancock & Kaiser, 1996; Roberts & Kaiser, 2012), children with intellectual disabilities (Kaiser & Roberts, 2012), children with autism (Hancock & Kaiser, 2002) and children who are nonverbal (Kaiser, Ostrosky, & Alpert, 1993). Children receiving EMT from therapists and/or parents have demonstrated increases in frequency of communication (Kaiser et al., 1993; Warren, Gazdag,

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Bambara, & Jones, 1994; Wright, Kaiser, Reikowsky, & Roberts, 2012), vocabulary (Kaiser et al., 1993; Scherer & Kaiser, 2010), and complex syntax (Kaiser & Hester, 1994; Warren & Kaiser, 1986). Children taught using EMT strategies maintained newly learned targets (Warren & Kaiser, 1986) and generalized across settings and people (Goldstein & Mousetis, 1989; Kaiser & Roberts, 2012; Warren & Bambara, 1989; Wright et al., 2012). In this paper, I will introduce the basic intervention strategies associated with the EMT naturalistic teaching approach and discuss specific accommodations when using the EMT approach with children who are AAC users. There are three specific objectives of the paper: 1. To review the key strategies of Enhanced Milieu Teaching 2. To identify the communication goals addressed in naturalistic communication intervention for toddlers and young children who use AAC 3. To discuss basic strategies for teaching EMT using AAC modes to parents and other communication partners

Supporting Communication in Young Children Who Use AAC Young children who are nonverbal or who evidence very limited spoken language abilities often are candidates for using additional modes of communication. These systems can act as an augmentative mode during their transition into spoken language or as an alternative to spoken language. Although children who have significant motor impairments that affect their production of oral language are the most frequent uses of AAC systems, increasingly, children with autism, children with Down syndrome, and children with significant intellectual disabilities learn to use AAC modes as a beginning communication system. The ease of producing communication using pictures, signs, or a speech-generating device is one clear advantage of AAC systems for young children. However, it also is important that the presence of a visual symbol (sign or picture) or a consistent auditory stimulus (word produced by a speech-generating device) may support language comprehension and contribute to development of understanding of spoken language. For an AAC system to be functional for young children, it must be used across everyday settings and particularly at home with family members. Preparing families to support AAC use is a challenging undertaking, and many speech-language pathologists have little training in either AAC systems or supporting parents in using AAC systems. Parents have reported that a lack of the speech-language pathologist’s knowledge of operation and implementation strategies for AAC systems have led to frustration and abandonment of the system as a communication mode (Bailey, Parette, Stoner, Angell, & Carroll, 2006). Supporting children who are learning language using an AAC system requires the adult to have specific skills in the communication mode, in addition to having strategies for modeling and responding to children’s communication. Although typical language interventions rely on modifying verbal input, modeling verbal forms, and responding to the child’s communication with expanded language, supporting a child who is using an AAC system requires the adult to use both his or her hands and voice to both provide language input and to respond to the child with both spoken and AAC models. The complexity of modeling in two modes simultaneously (spoken and AAC) and responding to children’s spoken and AAC-supported language challenges both professionals and parents.

Basic Assumptions of EMT Five basic assumptions about children, partners, and learning to communicate are foundational to EMT: (1) all children are communicators; (2) communication requires partners who respond to each other’s communication attempts; (3) adult partners teach new forms of communication by modeling them in context; (4) communication models by adults are most effective when they match the child’s focus and communicative intention; and (5) prompting is

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effective as a teaching tool when the response is functional for the child (that is, the production of the response allows the child to communicate a need or want that is then fulfilled by the adult). These basic principles are applicable regardless of the mode that the child is using to communicate. Thus, the core strategies of EMT are directed towards teaching forms in the context of communication and making communication relevant to the child’s interests, focus of attention, and preferences. In the following section, we outline the basic EMT strategies and then briefly discuss key adaptations made when teaching children who are AAC users. The seven core EMT strategies are summarized in Table 1. Table 1. Overview of EMT Components Component

Specific Strategies

Examples

AAC Adaptations

Play and Engage

•

Choose interesting and engaging toys

•

•

•

Join the child by actively playing with toys he or she chooses

Adult chooses blocks for a child at the pre-manipulative level

•

Adult models stacking the blocks, placing blocks in dump truck

Choose materials that match the child’s play and motor abilities

•

Teach target level play actions and sequences

•

Adult hands blocks to the child to place to sustain play

•

Adult models a routine of “put blocks in truck, dump blocks” •

Respond to child communication using the child’s mode and words

•

Make the AAC system or device immediately accessible to the child

•

Imitate child actions and model with the AAC mode

•

Respond to child communication using the child’s mode and words

•

Make the AAC system or device immediately accessible to the child

Notice and Respond

Balance Turn Taking

•

Sit face to face with the child

•

Adult sits across from the child, stacks blocks together

•

Follow the child’s lead

•

•

Respond to all child communication

Adult follows the child when the child moves from blocks to cars

•

Balance turns by responding to each child utterance with only one comment

•

Child vocalizes while playing with the baby and the adult responds by saying “baby.”

•

Child points to a toy on the shelf, and adult responds by labeling the toy “ truck”

•

Child babbles and points, adult responds with word, sign and point to object then waits for child to take another turn.

•

Child signs, “More blocks,” adult responds with “you need more blocks” and giving blocks, then waiting for child to take another turn.

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Mirroring and Mapping

Modeling and Expanding Communication

Environmental Arrangement (EA) Strategies

•

Imitate the child’s nonverbal actions (mirror) and map (model) language to these actions

•

Child makes a snowman with playdough, adult makes a snowman with playdough and models “make a snowman”

•

Model point, show and give gestures

•

Adult points to the apple and says “apple”

•

Model target signs or words

•

•

Expanding child communication by adding words and or symbols

Adult shows a dog while removing it from a box and labels it “ dog”

•

Adult models the word/sign “baby” while playing with the baby.

•

Child signs or says “baby” and the adult signs or says, “feed the baby”

•

Adult gives the child a juice box and waits for the child to ask for help, then models the phrase “ open juice” while opening the box

•

Adult holds up two choices and waits for the child to make a choice, then labels the choice as she gives it to the child

•

Adult gives the child a small amount of play-doh and waits for the child to request more, then says “more” as she gives play-doh to the child

•

Child requests the ball and the adult says “say, ‘ball,”

•

Adult holds up “juice” and “milk” and says “juice or milk?”

•

Assistance

•

Choices

•

Waiting with routine

•

Waiting with cue

•

Inadequate portions

Milieu

•

Open questions

Teaching Prompting Strategies

•

Choice questions

•

“Say” prompt

•

Least to most support sequence

•

Episodes begin with request and end with expansions

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•

Using mirroring and mapping including the ACC: Imitate child actions and model with the AAC mode and spoken words

•

Make the AAC system or device immediately accessible to the child

•

Model and expand using both spoken words and AAC mode

•

Prepare AAC to accommodate modeling targets and expansions

•

Choose EA that allow adult to control materials, offer choices, etc. and still have hands free to sign or use SGD

•

Build responding with AAC before introducing prompting

•

Prepare AAC to accommodate both primary targets and expansions modeled by partner

Strategy 1: Play and Engage Teaching communication occurs most easily when the child is engaged in an activity with the adult. Communication opportunities arise frequently during shared engagement around an object, an activity, or a routine. Shared engagement in an activity is more likely to occur when the adult is at the eye level of the child and facing the child. Additionally, child engagement is more likely when the activity is one the child prefers and when the child’s interests and actions lead the play or routine interaction. Allowing the child to lead the interaction requires the adult to notice the child’s focus of interest and engage in the activity with the child. The adult may extend the interaction and prolong joint engagement by adding objects or actions to the child’s play or arranging the environment to extend the interaction (e.g., by handing the child materials and setting up routines with multiple communication opportunities). The adult does not direct the play or interaction verbally with instructions or direct questions. The adult functions as an interaction partner first and indirectly as a teacher. Developing this platform of shared engagement is a prerequisite for communicative interactions, regardless of the mode the child is using. The adult should take care to arrange the environment so that the child can engage with the adult around the shared activity, yet still access and use his or her communication system. Equipment (SGD, pictures) should be easy for both the child and the adult to see and use while interacting with the materials associated with the play or routine. If the communication system is sign language, it is important that the child and adult are facing each other and are as close as possible to the same level so that they can both see each other’s communication. The adult should produce signs within the child’s visual range. The challenge for the adult is using the communication system while actively engaging with the child in the activity. For this reason, the simpler the activity can be while still maintaining the child’s interest, the easier it is for the adult to use the communication system while engaging with the child. As the adult becomes more fluent as a partner who both engages and uses the communication system, the adult and child can undertake more complex activities.

Strategy 2: Notice and Respond A responsive partner allows the child to take the lead in the “communication conversation” and responds to every attempt the child makes to communicate. By responding to the child’s attempts to communicate, the adult is reinforcing the child for initiating communication and encouraging him or her to continue communicating. Early communicators use many forms in addition to words to signal their interests, needs, and wants. Reaching, pointing, showing, grabbing, vocalizing, and simple signing (“more,” “all done”) are minimally linguistic forms of communication that the adult recognizes and responds to as communication attempts. Each child has unique forms and ways of communicating before she learns a standard mode such as words, signs, or pictures. Supporting early communication begins with adult partners who recognize the idiosyncratic communication forms and responds to these forms as communication. Typically, the adult partner responds by providing a more standard form that addresses the child’s communicative intent. Noticing communication requires more resources on the part of the listener when children use a mode that does not have a voice output feature, such as picture boards or sign language. Additionally, signs may not resemble the standard form or the child may point to a picture that the adult does not see. A responsive adult must notice the attempted communication and use the context (the child’s focus of attention and other aspects of the child’s behavior) to determine the child’s communicative intention in the moment. Although the adult may not read the child’s intention accurately on every occasion, increasing the adult’s attention to the child’s communication attempts is an essential first step in increasing the frequency of child communication. If the child appears to be communicating and the meaning

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is unclear, the adult should respond by modeling language based on what the child is doing or looking at while communicating. Ideally, a responsive adult will match the child’s intent by modeling language that the child would use if he or she could produce language through spoken or AAC modes. For example, the child may vocalize and make eye contact after placing a bottle in a baby doll’s mouth. A responsive adult takes a turn by matching the child’s communicative intent by saying “feed the baby,” while modeling the signs “feed” and baby” or using the child’s system to say the words. Statements (“Feeding the baby”) are preferable to questions (“Are you feeding the baby?”) because modeling a comment matches the child’s intention (to comment on his or her action). Responding with a question does not match the intent of the child’s communication and often elicits a yes or no answer that may end the communicative exchange. It is essential that the adult respond to the child’s communication using the child’s mode. The adult should set up the SGD or picture system within the child’s view and must model signs within the child’s field of vision. In order for the adult to link communication production with attention to the adult partner, it is important to take advantage of instances when the child is looking at the adult’s toys or his or her face. When the child is focused on the shared materials or the adult’s face, models using the AAC mode link models of communication forms with social engagement. Whereas spoken language only requires the child to use his or her auditory mode to perceive, augmented language requires the child to use a visual mode to be fully aware of the model. Using augmentative communication requires additional sensory resources beyond speaking and hearing. Managing play while modeling language in an AAC mode that requires use of hands requires practice. For example, holding a toy while responding to a child’s communication may necessitate the adult putting the toy down and briefly suspending play in order to model language using his or her hands to sign or to activate an SGD. The key considerations in noticing and responding with AAC users are (a) being aware of the child’s idiosyncratic communication forms using the AAC mode, (b) responding to the child using spoken language and the AAC mode; and (c) integrating responding using the child’s AAC mode into continued play and engagement with the activity or materials.

Strategy 3: Take Turns Turn-taking is the foundation of social communication. Children with significant communication impairments are likely to be low-rate turn-takers because of their limited use of modes of production and the challenges they face in producing communication across modes. Balancing turns in interactions introduces children to the structure of conversation and extends social communicative exchanges. Contingent, communicative responses to children’s turns signals that the adult has noticed the child’s communication attempt and is responding with related information. Ideally, contingent turn-taking reinforces the child for his or her communication attempt, and, over time, consistent responses to child turns should increase the frequency of these turns and the length of social communicative exchanges. When responding to the child’s communication, the adult should take a turn and then wait for the child to communicate again. By taking turns and pausing, the adult gives the child time to initiate communication and teaches him or her the early rules of conversational turns (e.g., you talk, and then I talk). Adult partners should take their communication turns using the child’s mode to demonstrate that it is a means of effective and efficient communication and to indicate to the child that the adult understands communication with this mode. Taking turns builds momentum in the social interaction and allows the adult to model new communication forms during his or her turn. Turn-taking may begin with a child’s nonverbal or vocal communication (gesture, vocalization, giving an object) but the contingent response by the adult (modeling spoken words and/or use of the AAC system) creates a high

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probability opportunity for the child to imitate the adult’s response and take his or her turn using a more advanced communication mode (words, sign, picture, or SGD). Extending turntaking interactions gives the adult opportunities to expand the emergent communication form used by the child. When turn-taking slows, or if the child does not initiate again to continue turn-taking, the adult may take one or two additional turns to prime the interaction; however, the overall goal is create a balance in turn taking that resembles a shared conversation. Too many turns by the adult indicates the adult is pushing the interaction rather than following the child’s lead. The child and the adult should use the same system. The adult partner should take his or her turn using the AAC system and spoken language so the child observes production in both the AAC and spoken modes. Placing the AAC system or materials between the adult and child and moving them as the child moves from one place or position to another is important because both partners must be able to access the mode quickly.

Strategy 4: Mirror and Map Responding to child communication ideally reinforces a child who is already communicating and provides new language models in response. Mirroring and mapping is a strategy that allows the adult partner to be responsive to a child who is NOT communicating but who is engaged with materials. In mirroring and mapping, the adult responds to the child by imitating the child’s actions and then describes their shared actions. For example, if the child is putting blocks into a shape sorter, the adult may mirror this action by putting blocks in the shape sorter after the child does (building a nonverbal turn taking structure to the interaction) and map the shared actions (the imitated action) with language by saying “in.” By joining in the activity with the child, the adult is creating an engaged context in which the child is more motivated to participate and learn new communication forms. By imitating the action first and then mapping the action with language, the model becomes more salient to the child. An adult can easily using mirroring and mapping using an AAC system. By completing the imitated nonverbal turn (e.g., putting the block in) before modeling the communication form (“in”), the adult has his or her hands available to model communication using signs, pictures, or an SGD. The adult will “map” shared actions using both spoken words and the AAC system.

Strategy 5: Model and Expand Communication In EMT, modeling language occurs primarily in response to child communication attempts. Balancing communication turns and following the child’s lead in the interaction are primary considerations during EMT. Thus, modeling new forms occurs when the child is engaged with the adult, interested in communicating, and likely to be able to notice and respond to the modeled form. Models of new spoken words and AAC-based forms are presented during turn-taking interactions and during mirroring and mapping episodes. Expanding the child’s communication is another strategy for modeling elaborated language when the child is already communicating. An expansion includes exactly what the child communicated and new content words. By imitating the child’s communication, new language is directly linked to what the child can already produce. Expansions help the child to learn new words when they are interested and communicating about an activity. Expansions can follow all forms of communication including vocalizations, gestures, and words. When a child vocalizes, the adult expands by replacing the vocalization with the content word she or he wants the child to say. The adult does not imitate the child’s vocalization in this case; she or he just models a content word. If the child is looking at or

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holding an object, the adult points to this object when saying the content word to increase the saliency of the word. If the child is playing with the object, the adult imitates the play action and models the target word. The adult can expand on a gesture by imitating the gesture or touching the object and adding specific content words. By imitating the gesture, the referent is confirmed and a label is given. For instance, if the child points to a puzzle, the adult points to the puzzle and say, “puzzle.” When it is not possible to imitate the gesture that the child does, the adult will touch or point to the object child is referring to before naming it. Finally, the adult can expand the child’s words to phrases by adding new words to the child’s utterance. By doing this, new language is connected to language the child already understands and uses. Adding words in this way increases the saliency of the new word and increases the likelihood that the child learns the new combination of words. For example, if the child says “drive,” an expansion could be “drive the car” or “I drive fast.” The adult should choose target words and phrases based on the child’s language level, interests and activities, and receptive and productive language levels. Target words are content words and semantically meaningful phrases that the child does not yet use to communicate spontaneously. Because request forms are easy to learn, we focus on functional use of communication forms for commenting, sharing information, and responding in EMT. For single-word users, typical target words include specific nouns (names for toys, people, materials, and places), verbs, and adjectives. We focus on content words rather nonspecific words that depend on the context for clear meaning (e.g., “it,” “this,” “that,” “here.”). Models of target phrases for two- and three-word users are based on early semantic relationships (e.g., Agent + Action, Action + Object, Agent + Action + Object). Spoken models include articles (Sue hit the ball), but AAC and sign models do not typically include these. Phrases such as “good job” and “yay” are not as useful for the language-learning child as specific descriptive praise (“you found the puzzle.” “You pushed the ball.”). Affirming descriptive statements provide both positive feedback and model words the child could say in this context. Positive body language, affect, and tone of voice help descriptive statements function as positive feedback to the child. Generally, adults will use spoken words and symbols on the ACC system together when modeling and expanding. Spoken words and signs or spoken words and symbols are presented simultaneously. When using AAC systems, it is important to anticipate the words and phrases that will be modeled during play and routine social interactions including possibilities for expansions. This includes knowing and being able to readily produce signs and preprogramming symbols to match the possibilities of play and social actions that could take place during an EMT session or in an everyday activity. When using systems that use picture symbols, smaller pages (either low-tech or hightech) may be dedicated to play expansions. For example, when playing with clay, one topic board or programmed page on a dynamic display could be dedicated to words about clay (soft, brown, smelly), the tools used with clay (knife, roller, cookie cutter) and the actions done with clay and tools (roll, push, cut, smash). Additional boards or pages can be made for possible extensions of this toy set. For instance, a food board would allow the play to turn into making pretend food out of clay or a body parts board would allow the play to develop into making people or snowmen. Even with advance preparation, it is always possible that the child will choose to play in a manner that was not anticipated (e.g., driving clay cars over the edge of the table). In this case, the core words programmed for the toy set may be the only words you can model using the AAC system, and other new vocabulary will have to be modeled verbally.

Strategy 6: Environmental Arrangement to Promote Communication During EMT interactions, the adult arranges the environment to set up nonverbal cues to encourage the child to communicate. Examples of environmental arrangements are giving nonverbal choices, pausing in a routine, waiting with a cue to communicate, providing

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inadequate portions of a preferred material, and setting up an activity in which the child will need assistance. In each of these environmental arrangement strategies, the adult sets up the physical and social environment and waits for the child to communicate. When the child communicates using any form (vocalization, gesture, sustained looking), the adult gives the object or action requested and expands the child’s communication attempt by modeling a target level form (e.g., use of the AAC system, handing a picture, words plus sign). If the child does not communicate in response to an environmental arrangement, this indicates that he or she does not want or is not interested in the object or action at this time. When this happens, the adult should abandon the presentation of an environmental arrangement, not provide the item or activity to the child, and return to interacting with the child and the toys or materials at hand. We begin by using environmental arrangement as a cue for communication to increase nonverbal requesting. Initially, we respond to their communication attempts with the desired objects or actions and giving a label (spoken word plus sign, picture, or SGD response). Prompting and using sequences of least-to-most supportive prompts to guide a child to a correct response is introduced after the child is communicating in response to environmental arrangements. During environmental arrangement episodes, the adult gives the child the item or activity she or he has requested immediately before modeling the communication form. Thus, the adult’s hands are free to model using spoken words and the AAC system. The challenge is to present the model in both modes before the child shifts his or her focus attention to the object she has just received.

Strategy 7: Using Milieu Teaching Prompts A prompt is a verbal cue to provide a specific communicative response. Milieu teaching prompts are sequences of adult behaviors that elicit child target level communication responses. Milieu teaching prompts offer increasingly explicit support for producing that response and conclude with semantic feedback in the form of an expansion. Prompts occur when the child has made a nonverbal or verbal request that is below his or her target level. The prompting sequence is designed to teach the child the specific verbal response that will result in obtaining the desired object or action he or she has requested. In Figure 1, I summarize the principles that guide the use of milieu teaching prompts. Figure 1. Guidelines for Using Milieu Teaching Prompts

Milieu Teaching Prompts • • •

•

•

•

Always begin with a child request Adult responds to child request with a verbal prompt for a specific form Adult prompts include open questions, choice questions, and prompts to imitate (“say prompts)” in a least to most support sequence Incorrect or nontarget child responses are followed by additional, more supportive prompts to support production of the response Correct target responses are followed by access to the requested object or action and an expansion of the child’s verbal request Prompting should be natural, brief and integrated 45 into the flow of interaction and conversation.

Prompting provides children opportunities to practice new, more elaborate communication forms in functional contexts with support from an adult. The adult embeds prompts in ongoing conversation always in response to child requests. By teaching to child requests, the adult ensures that there is a functional consequence (a child-specified reinforcer) for the child’s response to the adult’s prompt. The adult organizes a prompting sequence to provide least-to-most support for the child to respond. For example, following a child’s request that is below their target level (e.g., reach, vocalization), the adult may ask an open-ended question (“What do you want?”). If the child cannot respond to this question, the adult may follow up with a choice question (“Do you want play dough or cars?”). If the child makes a choice, but does not provide a communicative response (sign, spoken word, or AAC response), the adult may use a direct “say” prompt that asks the child to imitate (“Say cars”). See Hancock and Kaiser (2006) for more detailed descriptions of milieu-prompting sequences. Prompting always occurs after the child has requested a desired object of action. Frequently, the adult will have access to a preferred material or activity. One of the challenges in adapting milieu teaching prompts for AAC users is the adult having hands available to sign, hand pictures, or communicate using an SGD while holding materials (offering choices) or pausing within a routine (e.g., holding a ball at the top of a ramp; opening the container of crayons). Additionally, implementing a “say” prompt for children who use sign language may require use of both hands to model and physically support children’s production of the sign. In these cases, it is important for the adult to be creative in maintaining control of materials during prompt sequences, be fluent in the prompting procedures so that the prompting sequence is relatively short in duration, and initially prompt words, signs, or symbolic exchanges that are relatively easy within the system the child uses. Because the adult will conclude the milieu teaching prompt episode with an expansion that requires using two or more symbols, he or she will give the child the requested material, then model the expanded utterance (“we eat cookies”) using both spoken words and the AAC mode. Thus, it will be essential to select and arrange symbols (SGD, pictures) appropriate for requesting and for expanding the child’s utterances. Prompting is used at a relatively low rate during EMT. Given the challenges in implementing milieu teaching prompt sequences effectively, it is important to prioritize which child targets will be prompted and which will be taught through modeling and expansions. In all cases, advance preparation and practice will be necessary for fluent implementation.

Goals for Early Communicators Goals are addressed in two ways in EMT. First, each child has goals related to functional use of communication. These goals are: (1) to increase the frequency of functional communication; (2) to increase the diversity of forms used for functional communication; (3) to increase the complexity of forms for functional communication; and, (4) to ensure generalized use of functional forms across settings, communication contexts, and partners. For children who use spoken language and children who use AAC systems to communicate, the primary goal is always to increase their spontaneous, social communication and to build their repertoire of forms and functions over time. EMT is designed to teach and support functional communication, and these broad goals are consistent with key strategies used in EMT. Within this general framework of goals, each child has specific linguistic targets that may include vocabulary and combinations of words. As children progress in communication skills, they will have word combination goals that eventually become syntax goals. Early vocabulary includes protoverbs (on, in, up, more, again); protests (no, stop); nouns (labels for objects); verbs (action words); and modifiers (color, shape, size, texture, taste/smell). Children typically start with small sets of words that can be used across contexts, then specific words for daily routines and preferred activities are introduced, with the goal of increasing vocabulary continuously based on child performance. Early word combinations reflect early semantic

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meanings: my + object, no + action or object, action + object, agent + action, preposition + location, and modifier + object. Adults teach functional requesting targets (e.g., I want + object), but EMT emphasizes linguistic targets that children and adults can use for a range of pragmatic functions. For children using AAC systems, there are many considerations in choosing goals. The goals for functional communication essentially will be the same for children using spoken language and AAC systems. The linguistic goals may be selected or grouped differently for ease of production, location within the system, and other considerations. A critical decision for later communicators will be whether to emphasize learning the semantic and syntactic bases of spoken language or to teach immediately accessible multiword forms without regard for semantics and syntax; however, early functional communication goals and single-word vocabulary targets are generally similar across children. When including teachers and parents as EMT intervention partners, experts recommend that adults teach simpler, easier to produce, child linguistic targets while the partner is acquiring and initially practicing EMT strategies.

Strategies for Teaching Partners We have taught parents, teachers, siblings and others to use EMT strategies using a range of approaches adapted to the context and purposes of training. Most often, we train communication partners using a “teach-model-coach-review” sequence to teach the five major components of EMT. Table 2 summarizes these adult teaching strategies.

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Table 2. Strategies for Teaching EMT to Partners Component Teach

Model

Purpose •

Introduce new information about EMT strategies

•

Provide a rationale for using and EMT strategy

•

Introduce terminology

•

Individualize information for the child and partner

•

Include use of the AAC system in the teaching activities, both workshops and individual practice sessions.

•

Demonstrate the specific EMT strategy with the target child in routine or play.

•

Interactive workshops with individualized power point and handouts

•

Brief teaching session and handouts of information at the beginning of individual sessions

•

In vivo modeling in play and routines

•

Modeling includes use of spoken words and the AAC system

Trainer models and describes what she is doing

•

Video models using positive examples of the parents behavior

•

Video models of how to use strategies in specific routines

•

Support partner in using EMT strategies during interactions with the child

•

In vivo coaching, supplemented with graphic feedback, video examples, or written feedback after each session

•

Provide immediate feedback and guidance to improve implementation

•

Coaching includes use of EMT strategies and AAC mode

•

Formative evaluation of the implementation by the partner

•

•

Include both use of EMT strategies, use of AAC system in evaluation

Trainer and partner reflect on implementation, evaluate partner and child behavior during practice sessions, and plan for future implementation at home

•

Consider impact of EMT intervention on child

•

Coach

Review

Example Formats

The “teach” component is typically a short workshop presentation about the intervention component. The workshop is individualized to the trainee or group of trainees and includes an introduction to the EMT strategy, operational definitions, and a rationale for using the strategy with the target child population. The “model” component of training includes the trainer (often the child interventionist) modeling the EMT strategies with the target child and video models of the strategies with similar children. During the “coach” component, the adult receiving training practices each skill with the target child and receives in vivo coaching from the trainer. The goal of the coaching sessions is to provide enough support for the trainee to gain skill and have a positive practice experience where she can see the impact of his or her behavior on the child’s communication. The “review” component follows the practice session and includes reviewing the adult and child’s behavior during practice session, analyzing strengths and challenges in implementing the EMT strategies, and making a plan for next steps in learning the strategies. The EMT strategies build on each other. Thus, it is essential to teach

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noticing and responding, modeling and expanding before moving on to environmental arrangement and milieu prompting strategies. The best trainers for partners who will use EMT with AAC users are interventionists who are experienced and fluent in both EMT and the specific AAC system used by the target child. It is essential to be able to model use of the system while also demonstrating the EMT strategies. The skills for trainers also include the ability to describe and define the EMT strategies, model each EMT strategy in context, observe and analyze partner and child behavior as a basis for giving in vivo, and follow up feedback to improve the implementation of EMT. Trainers often are problem-solvers, adapting the EMT intervention to fit the child, the context, and the partner’s skill with the goal of building successful naturalistic teaching-learning experiences. Adults may be trained in basic use and, if appropriate, programming the AAC mode prior to EMT training but we recommend the continued introduction of signs, pictures, and symbols within the EMT training sessions. As partners become more fluent in use of the EMT strategies, their opportunities for using the AAC mode across settings and activities will expand, and thus, their need for more signs, pictures, or symbols to support communication also will expand. The SGD may require development of pages at different levels to support specific activities and play routines. Ultimately, partners must be able to manage the AAC system. However, we recommend beginning the EMT training while providing maximum support for the use of the AAC mode. This allows the partner to focus on learning the naturalistic teaching skills and using the mode effectively. Using EMT in routines and everyday conversations is the core of this naturalistic teaching strategy. Teaching partners to identify routines, to assess children’s communication needs in these routines, and to use EMT strategies with the AAC system in these settings is key to building and sustaining their use of both the EMT strategies and the AAC system. By modeling within routines and providing parents with tools supporting their children in everyday interactions during partner training, it is possible to increase the ease of everyday communication between children and their partners and to create new teaching and learning opportunities for children who are learning to use an AAC system.

Conclusions Children with complex communication needs require intentional, evidence-based interventions that can be implemented in natural environments and used by parents and other adult communication partners. EMT is an evidence-based intervention that can be adapted for children who are AAC users. Infusing AAC into EMT strategies requires preparation, practice, and fluency in both the EMT strategies and use of the AAC system. Speech-language pathologists who are skilled communication interventionists themselves can teach parents and other partners to use EMT with AAC users.

Dr. Ann Kaiser is the Susan W. Gray Professor of Education and Human Development at Peabody College of Vanderbilt University. She has published more than 100 articles and chapters on early language interventions for children with language delays, children with developmental disabilities, and children at risk due to poverty. Courtney Wright, MA, CCC-SLP is a doctoral candidate at Vanderbilt University in the Early Childhood Special Education program. She is a licensed speech-language pathologist specializing in children with developmental disabilities and

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augmentative and alternative communication. She is child interventionist and parent consultant on KidTalk early communication intervention projects.

References Bailey, R. L., Parette, H., Stoner, J. B., Angell, M. A., & Carroll, K. (2006). Family members’ perceptions of augmentative and alternative communication device use. Language, Speech & Hearing Services in Schools, 37, 50–60. Goldstein, H., & Mousetis, L. (1989). Generalized language learning by children with severe mental retardation: Effects of peers’ expressive modeling. Journal of Applied Behavior Analysis, 22, 245–259. Hancock, T. B., & Kaiser A. P. (1996). Siblings’ use of milieu teaching at home. Topics in Early Childhood Special Education, 16, 168–190. Hancock, T. B., & Kaiser, A. P. (2002). The effects of trainer-implemented enhanced milieu teaching on the social communication of children who have autism. Topics in Early Childhood Special Education, 22, 39–54. Hancock, T. B., & Kaiser, A. P. (2006) Enhanced milieu teaching. In R. J. McCauley & M. E. Fey, Treatment of language disorders in children (pp. 203–236) Baltimore, MD: Paul H Brookes. Kaiser, A. P., & Hester, P. P. (1994). Generalized effects of enhanced milieu teaching. Journal of Speech and Hearing Research, 37, 1320–1340. Kaiser, A. P., Ostrosky, M. M., & Alpert, C. L. (1993). Training teachers to use environmental arrangement and milieu teaching with nonvocal preschool children. The Journal of the Association for Persons with Severe Handicaps, 18(3), 188–199. Kaiser, A. P., & Roberts, M. Y. (2012). Parent-implemented enhanced milieu teaching with preschool children with intellectual disabilities. Journal of Speech, Language, and Hearing Research. Advance online publication. doi:10.1044/1092-4388(2012/11-0231) Scherer, N. J., & Kaiser, A. (2010). Enhanced milieu teaching/Phonological emphasis: Application for children with cleft lip and palate. In L. Williams, S. McLeod, & R. McCauley (Eds.) Interventions for speech sound disorders in children (pp. 427–452). Baltimore, MD: Paul H. Brookes. Warren, S. F., & Bambara, L. M. (1989). An experimental analysis of milieu language intervention: Teaching the action-object form. Journal of Speech and Hearing Disorders, 34, 448–461. Warren, S. F., Gazdag, G. E., Bambara, L. M., & Jones, H. A. (1994). Changes in the generality and use of semantic relationships concurrent with milieu language intervention. Journal of Speech and Hearing Research, 37, 929–934. Warren, S. F., & Kaiser, A. P. (1986). Generalization of treatment effects by young language-delayed children: A longitudinal analysis. Journal of Speech and Hearing Disorders, 51(2), 239–251. Wright, C., Kaiser, A., Reikowsky, D., & Roberts, M. (2012). Effects of a naturalistic sign intervention on expressive language of toddlers with Down syndrome. Journal of Speech, Language, and Hearing Research. Advance online publication. doi:10.1044/1092-4388

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Fundamentals of the ImPAACT Program Jennifer Kent-Walsh Cathy Binger Disclosure: Jennifer Kent-Walsh has no financial or nonfinancial relationships related to the content of this article. Disclosure: Cathy Binger has no financial or nonfinancial relationships related to the content of this article.

Abstract Researchers widely agreed that working with communication partners is a critical component of any AAC intervention program. However, it can be difficult for clinicians to know how to structure this type of indirect intervention to do more than “tell” communication partners of individuals using AAC what they “should” be doing. The ImPAACT Program is one intervention program that has been documented to yield positive results for clients using AAC. The program involves a structured multistep approach to intervention that users can customize for use across a range of communication partners, clients, and instructional contexts. In this article, we provide an overview of the program’s instructional content, approach, and basis of evidence. When reflecting on why they originally entered the field of communication sciences and disorders, many professionals undoubtedly think back to seminal experiences that resulted in a desire to impact the everyday lives of clients with communication disorders. Whatever the specific circumstance, for example, caring for a family member or interacting with a friend with a communication disorder, it is highly likely that the situation involved some type of interaction with a key communication partner in “the real world.” For professionals who work with clients with complex communication needs, the need to facilitate functional interactions for individuals who cannot meet all of their communication needs via speech is often apparent. Yet, despite the desire to positively influence our clients’ interactions with communication partners, many of us still struggle to provide appropriate communication partner interventions that yield lasting positive outcomes in our clients’ communication. Even when we know what we want communication partners to do or change, we often struggle with how we can work with them to get them to a point where those changes in interaction style happen consistently and naturally. As a follow-up to a recent Perspectives article (Binger & Kent-Walsh, 2012), in which we examined options for identifying appropriate communication skills to target with individual communication partners, in this article, we will focus on the next step in partner intervention— the execution of a partner instruction program. We will present a suggested approach for implementing communication partner interventions following identification of instructional goals. To complement the range of other communication partner instruction options covered in this issue, as well as the previous issue of Perspectives, we will detail the ImPAACT Program (e.g., Binger, Kent-Walsh, Ewing, & Taylor, 2010; Kent-Walsh, Binger, & Hasham, 2010).

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Following some background information on the development of the ImPAACT Program, we will present an overview of the program steps and the evidence supporting the effectiveness of this program to date.

Frustrations and Approaches to Communication Partner Instruction Clinicians and researchers consistently note concerns about a number of less-thanideal communication behaviors. Observations and measurements of the following communication partner tendencies within ImPAACT Program studies (e.g., Binger et al., 2010; Kent-Walsh et al., 2010) are consistent with those issues researchers have long reported in the literature (e.g., Cumley & Beukelman, 1992; Light, Collier, & Parnes, 1985): •

Dominating interactions

•

Asking predominantly yes/no questions

•

Taking the majority of conversational turns

•

Providing few opportunities for client initiation or response

•

Interrupting communicative attempts

• Focusing disproportionately on the technology Because clinicians often want to change these behaviors as quickly as possible in efforts to facilitate supportive communicative environments for their clients, there is a tendency to immediately “jump in” with some quick fixes. Our experiences suggest that as clinicians, we also have some not-so-effective tendencies. For example, clinicians have the best of intentions when they provide simple explanations for how to improve interactions (e.g., “Make sure Maria’s device is available during this activity, and show her some examples of what she might say”). Even when clinicians are careful to not take a “preaching” approach and instead offer suggestions and check in with partners to see how things are going, often, they often end up with frustrating results. In addition, communication partners can end up feeling inadequate or isolated and clients often experience unchanged interactions with those who mean the most to them. These kinds of scenarios highlight the need to focus directly on building the partners’ skills instead of placing the focus on knowledge. To assist with overcoming these obstacles, the ImPAACT approach includes a threepronged approach to partner instruction: (1) select appropriate targets for communication partners to coordinate with carefully selected client targets (e.g., Binger & Kent-Walsh 2012), (2) use effective instructional techniques, and (3) purposefully structure communication partner intervention programs. In the remainder of the article, we will provide a detailed description of the second and third steps and illustrate them within the context of the ImPAACt program.

The ImPAACt Program: A Communication Partner Instructional Protocol In 2005, Kent-Walsh and McNaughton provided an overview of communication partner instruction issues as presented in the AAC literature up to that time. They suggested that despite indications in the literature that communication partner instruction was a critical intervention component and evidence to indicate that communication partner instruction could be effective, researchers were paying little attention to the most effective and efficient methods to conduct communication partner interventions. In light of these facts and important findings in other related fields such as education (e.g., Ellis, Deschler, Lenz, Schumaker, & Clark, 1991; Harris & Pressley, 1991), Kent-Walsh and McNaughton proposed an eight-step strategic model for use in communication partner instruction programs. As such, a strategy instruction was formally proposed for use in communication partner instruction in AAC.

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Strategy instruction is a method for teaching individuals to apply a series of multistep procedures to address a specified challenge (i.e., Kent-Walsh & McNaughton, 2005). In essence, individuals follow a series of defined steps in order to accomplish a complex task. In the context of communication partner instruction, it is important to consider the component instructional techniques or skills that clinicians will teach communication partners, the specified manner in which partners will implement these skills, as well as the manner in which the instructor will implement the instructional program (i.e., the instructional approach). The ImPAACT Program is based on Kent-Walsh and McNaughton’s proposed strategy instruction protocol and was designed specifically to support communication partners in the facilitation of the language communication skills of children with developmental disabilities using AAC. Although the program was originally designed with a focus on pediatric clients, it is presented for consideration and future evaluation with clients across the lifespan.

Instructional Content Target Skills To date, the ImPAACT program has involved a consistent set of component skills that experts have taught communication partners of children using AAC to implement. Developers identified these skills through a review of the literature, researchers have documented these to be effective in supporting the communication of clients using AAC (e.g., Binger & Light, 2007; Kent-Walsh & McNaughton, 2005). In Table 1, we provide an overview of these skills and describes the associated implementation goals. The first four skills in the table—aided AAC modeling, expectant delay, wh-question asking, and verbal prompting—are techniques to prompt the client to communicate; the final skill—contingent responding—is intended to reinforce the client’s communicative attempts. Table 1. An Overview of Skills Targeted Using the ImPAACT Program Communication Skill

Type of Technique

Implementation Goal

Aided AAC Modeling

Prompt

Provide functional models of effective AAC use

Expectant Delay

Prompt

Provide communication opportunities, additional processing time, and an expectation for communication

Wh- Question Asking

Prompt

Prompt higher-level content expression

Verbal Prompting

Prompt

Provide direct indication of what to do

Contingent Responding

Response

Reinforce communicative attempts and supports utterance expansion

Strategic Application of Target Skills Although it is important to clearly describe and review individual communication skill targets with communication partners, partners often do not automatically know how to implement these skills in conjunction with one another. This is where strategy instruction comes into play. By formulating a strategy that involves the sequential implementation of individual communication skills, communication partners have a clear guide they can follow to ensure that they are maximizing the benefits of the above-described prompts. For example, clinicians using the ImPAACT program essentially use the prompts listed above as a modified “least-to-most” prompting hierarchy, as illustrated in the examples below;

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that is, they give as few prompts as possible to elicit the target from the client. Although there undoubtedly will be instances where “most-to-least” prompting hierarchies will be most appropriate (e.g., when eliminating challenging behaviors), clinicians consistently have used a modified “least-to-most” approach within the ImPAACT program. Because the associated communication targets for the children who have participated in the ImPAACT program to date largely have been skills that these children already had acquired receptively, clinicians made attempts to try to avoid the need to fade highly directive prompts over time by employing only the prompts that are necessary to elicit a communicative attempt (e.g., communicative turn, multi-symbol utterance). In the following examples of ImPAACT program strategies, we illustrate how clinicians can target the component skills within a structured communication strategy. In a study involving African American and European American parents (Kent-Walsh et al., 2010), researchers taught parents to implement the “RAA” strategy (Read, Ask, Answer) during interactive storybook reading activities. Each time the parents turned a page in the book, they learned to implement a least-to-most cuing hierarchy comprised of the following steps: 1. “Read” + provide an aided AAC model; 2. “Ask” a wh-question + provide an aided AAC model; 3. “Answer” the wh-question + provide an aided AAC model. Parents learned to implement an expectant delay after each step and provide contingent responses to the children’s communicative turns. In aided AAC models, the communication partners supplemented their spoken messages by accessing the child’s SGD. They could use aided AAC before, during, or after the spoken message. As per the goal of this instructional program, participating children demonstrated increased turn-taking during interactions with their parents when their parents implemented the targeted interaction strategy. In another ImPAACT program study involving educational assistants, the goal was to increase the participating children’s multisymbol message productions via aided AAC (Binger et al., 2010). As such, researchers taught the participating educational assistants to implement the following “RAAP” interaction strategy until the children produced multisymbol utterances using their SGDs: 1. “Read” text + provide two-symbol aided AAC model (i.e., provide a spoken model of a multisymbol message and also use two symbols on the student’s SGD; Binger & Light, 2007); 2. “Ask” a wh-question + provide a two-symbol aided AAC model; 3. “Answer” the wh-question + provide a two-symbol aided AAC model; 4. Provide a brief verbal “prompt” (e.g., “Your turn” or “Show me two”). Between each of the above steps, researchers taught the educational assistants to provide an expectant delay of at least 5 seconds in order to provide the children with opportunities to take turns. Finally, they instructed the educational assistants to respond contingently to each multisymbol message the children produced by producing an aided AAC model containing at least two symbols. These responses typically took the form of imitations, expansions, extensions, and corrections. Because some Latino children may view the use of an expectant facial expression as punitive, researchers did not require the educational assistants of the participating Latino children to maintain an expectant facial expression during the expectant delay.

Instructional Approach In recent years, researchers have considered various aspects of preferences for AAC instruction (e.g., Burke, Beukelman, Ball, & Horn, 2002; Crema & Moran, 2012; Thiessen,

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Horn, Beukelman, & Wallace, 2011). When considering adult learning, for example, recent findings indicate there is variability with regard to preferences toward such aspects as learning mode (Beukelman & Thiessen, 2013). Some adult learners may indicate preferences toward learning through case studies, in group environments, or through step-by-step approaches, for example (Thiessen et al., 2011). Despite these noted variations, it is important to recognize that the commonly identified trait of learners preferring to learn information that is relevant and useful (e.g., Knowles, Holton, & Swanson, 1998) reportedly holds true for adult communication partners or facilitators (e.g., Thiessen et al., 2011). The ImPAACT program outcomes suggest that researchers can adapt the program for use with a range of partners including parents, educators, and peers. In this section, we will detail the instructional components of the ImPAACT Program and the instructional sequence. Instructional Components There are five main instructional techniques or components within the ImPAACT Program: (a) video review, (b) modeling, (c) role play, (d), verbal rehearsal, and (e) coached practice. Instructor employ video review to offer communication partners “real world” illustrations of the communication skills and strategies that become the focus of the instructional program. In some cases, seeing really is believing, so instructors may employ video review at the beginning of the ImPAACT Program instructional sequence and then again at the end of the sequence to both detail and reinforce targeted skills and strategies, as well as the associated effects on the language and communication skills of the clients using AAC. Instructors also use modeling (i.e., live demonstrations) used to illustrate targeted skills and strategies through live demonstrations followed by extensive role play. Role play affords communication partners opportunities to practice the skills and strategies they are learning in a more controlled environment. For example, the clinician may remove any real-life challenging client behavior variables within role plays as the partner is first learning to implement the targeted skills/strategies and then gradually introduce those variables as the partner is gaining confidence in implementation. Similarly, the ImPAACT program involves the fading of provided constructive feedback (both positive and corrective) within the context of coached practice. The final instructional technique in the ImPAACT program is verbal rehearsal. This technique relates to learning the pneumonic associated with the strategy sequence as described in the earlier examples of “RAA” and “RAAP” strategies. ImPAACT program participants and instructors take turns repeatedly naming the steps in the pneumonic (Read, Ask, Answer, and always model, wait, and respond; Read, Ask, Answer, Prompt, and always model, wait, and respond). Instructors use this technique to increase the automaticity of communication partners’ implementation of the targeted strategy. Instructional Sequence In Table 2, we provide a detailed account of how instructors employ each of the abovedescribed techniques across a series of instructional steps. As noted in the column “Session Number,” there is variability in the number of ImPAACT Program steps instructors employ within a given session. In some cases, partners may feel comfortable and demonstrate mastery in covering the first five steps within a 1-hour instructional session, whereas other partners may require additional time. The length of time for individual sessions also can vary as needed. Researchers in ImPAACT Program studies has shown that the total instructional time required to complete the entire ImPAACT Program instructional sequence may vary anywhere from 1.5– 5 hours of total instructional time across 1–6 sessions.

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Table 2. ImPAACT Program Steps ImPAACT Program Step

Session Number

Goal

Instructional Activities within Specified Context

1. Pre-test & Commitment

1

•

Provide illustrations “with” and “without” use of targeted strategy.

•

Obtain formal commitment to completing instruction.

•

Review “pre” and “post” videos of another client.

•

Discuss differences in partner & client communication.

•

Review and sign a contract document outlining all instructional activities.

2. Strategy description

1

•

Describe targeted strategy and component skills.

•

Provide and review a visual aid/handout with an outline of each component skill within targeted strategy.

3. Strategy demonstration

1

•

Model use of the targeted strategy and its component skills.

•

Role play with clinician playing role of partner and partner playing role of the client.

•

Provide metacognitive explanations of all steps.

•

Provide “think-aloud” statements.

4. Verbal practice of strategy steps

1–3

•

Increase automaticity in executing strategy components.

•

Rote verbal rehearsal; practice naming each strategy component in order with use of a pneumonic (e.g., RAAP = Read, Ask, Answer, Prompt)

5. Controlled practice feedback

1–3

•

Provide multiple opportunities for practice of targeted strategy in controlled environment.

•

Role play with partner playing role of self and clinician playing role of the client.

•

Provide and gradually fade verbal feedback (both positive and corrective) within “errorless learning” approach.

•

Gradually increase the variety of and complexity of client behaviors/responses.

Provide multiple opportunities for practice of targeted strategy in natural environment.

•

Live interaction between partner and client in the natural environment.

•

Provide and gradually fade verbal feedback (both positive and corrective) within “errorless learning” approach.

Provide illustration of learning/improvements in strategy implementation and positive changes in client’s communication.

•

Review “pre” and “post” videos of partner interacting with the client.

•

Elicit discussion on partner identified differences in partner and client communication and associated impact/value.

•

Generate an action plan to encourage generalized long-term strategy use.

6. Advanced practice and feedback

4–6

7. Post-test & commitment

Final session

8. Generalization

Final session

•

•

Provide support in learning how to generalize use of targeted strategy.

Live interaction between partner and client within additional activities (aside from the specified instructional context) in the natural environment. Provide and gradually fade verbal feedback (both positive and corrective) within “errorless learning” approach.

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Evidence to Date Although a detailed evaluation of the evidence associated with the effectiveness of the ImPAACT Program is beyond the scope of this paper, we provide an overview. Of particular interest may be the demographics of the participants described across the eight studies included in Appendix A. A total of 34 communication partner-client dyads participated in the included ImPAACT Program studies. Participating children and communication partners ranged in age from 3 years, 4 months to 12 years, 7 months. These children had a range of primary medical diagnoses (e.g., autism spectrum disorder, cerebral palsy, developmental delay, Down syndrome, intellectual impairment, suspected childhood apraxia of speech) and were from a range of cultural and linguistic backgrounds (e.g., African American, European American, European Canadian, Latino). These children also used a range of AAC devices, including both low-tech and high-tech systems, and evidenced a range of receptive language skills, including those within normal limits and those which could be characterized as notably delayed or impaired. Although the reader is referred to the individual studies for complete findings, each of the studies referenced in Appendix A reported improvements in both communication partner implementation of targeted interaction strategies and the participating children’s communication skills. Specifically, participating children have evidenced improvements in pragmatic skills (e.g., increased turn-taking rates), semantic skills (e.g., increased vocabulary diversity), and morpho-syntactic skills (e.g., increased message length/complexity). These findings are encouraging in light of relatively limited instructional demands (i.e., 1.5–5 hours).

Conclusions Communication partner instruction can be an important component of intervention programs for clients with complex communication needs. The ImPAACT Program is one intervention program researchers have documented to yield positive results for pediatric clients using AAC. The program involves a structured multistep approach to intervention that clinicians can customize for use across a range of communication partners, pediatric clients, and instructional contexts. Further research is required to examine the effectiveness of the ImPAACT Program with additional client and partner populations, including adult client populations.

References Burke, R., Beukelman, D., Ball, L., & Horn, C. (2002). AAC technology learning, part I: AAC intervention specialists. Augmentative and Alternative Communication, 18, 242–249. Binger, C., & Kent-Walsh, J. (2012). Selecting skills to teach communication partners: Where do I start? Perspectives on Augmentative and Alternative Communication, 21, 127–135. Binger, C., Kent-Walsh, J., Ewing, C., & Taylor, S. (2010). Teaching educational assistants to facilitate the multi-symbol message productions of young students who require AAC. American Journal of SpeechLanguage Pathology, 19, 108–120. Binger, C., & Light, J. (2007). The effect of aided AAC modeling on the expression of multi-symbol messages by preschoolers who use AAC. Augmentative and Alternative Communication, 23, 30–43. Crema, C., & Moran, N. (2012). Training speech language pathologists of adult clients on the implementation of AAC into everyday practice. Perspectives on Augmentative and Alternative Communication, 21, 37–42. Cumley, G. D., & Beukelman, D. (1992). Roles and responsibilities of facilitators in augmentative and alternative communication. Seminars in Speech and Language, 13, 111–118. Ellis, E., Deshler, D., Lenz, B., Schumaker, J., & Clark, F. (1991). An instructional model for teaching learning strategies. Focus on exceptional children, 23(6), 1–24.

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Harris, K., & Pressley, M. (1991). The nature of cognitive strategy instruction: Interactive strategy construction. Exceptional Children, 57, 392–404. Kent-Walsh, J., Binger, C., & Hasham, Z. (2010). Effects of parent instruction on the symbolic communication of children using AAC during storybook reading. American Journal of Speech-Language Pathology, 19, 97–107. Kent-Walsh, J., & McNaughton, D. (2005). Communication partner instruction in AAC: Present practices and future directions. Augmentative and Alternative Communication, 21, 195–204. Light, J., Collier, B., & Parnes, P. (1985). Communicative interaction between young nonspeaking physically disabled children and their primary caregivers: Part 1: Discourse patterns. Augmentative and Alternative Communication, 1, 74–83. Thiessen, A., & Beukelman, D. (2013). Training communication partners of adults who rely on AAC: Coconstruction of meaning. Perspectives on Augmentative and Alternative Communication, 22, 16–20. Thiessen, A., Horn, C., Beukelman, D., & Wallace, S. E. (2011). Learning motivation of adults involved in AAC intervention. Perspectives on Augmentative and Alternative Communication, 36, 69–74.

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Appendix A: Demographic Information of Participants in Previous ImpAACT Studies Study

Children's Chronological Ages & Gender

Children's Ethnicity

Children's Primary Diagnoses

Children's Aided AAC Systems

Children's Reported Language Level Range

Children's Outcome Measure Type

Partner Role & (Ethnicity)

Instructional Context & Activity

Component Skills in Targeted Partner Communication Strategy

Binger, KentWalsh, Berens, Del Campo & Rivera (2008)

N = 3 4;1 (male) 3;4 (female) 2;11 (female)

Latino (3)

PPD (1), Suspected VCFS & CAS (1), Cleft Palate (1)

Low-Tech Communication Board (1), SGD (2)

TACL-3 Standard Score Range: 106-109

Multi-modal communicative turns (Frequency)

N = 3 Parents (Latino - 3)

Individual instruction; Storybook reading

Aided AAC modeling, Expectant delay, Wh- question asking, Contingent responding

Binger, KentWalsh, Ewing & Taylor (2010)

N = 3 6;4 (male) (6;4 male) 5;8 (female)

Latino (2), European American (1)

DD (1), DD & Suspected CAS (1), Dysarthria & CP (1)

SGD (2), PECS (1)

TACL-3 Standardized Score Range: 61-98

Multisymbol SGD messages (Frequency), Spontaneous symbol combinations (Frequency), Novel symbol combinations (Frequency)

N = 3 Educational Assistants (AfricanAmerican - 1; Latino - 1; , Latino/Anglo -1)

Individual Instruction; Storybook reading

Aided AAC modeling, Expectant delay, Wh-question asking, Whquestion answering, Verbal prompting, Contingent responding

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KentWalsh (2003)

N=5 4;3 (male) 12;7 (female) 3;0 (male) 11;5 (male) 9;0 (female)

European American (2) European Canadian (3)

Suspected DAS (2), DS (2), DD (1)

Low-Tech Communication Board (4), SGD (1)

PPVT-III Standard Score Range: 40-99; TACL3 Standard Score Range: 42-106

Percentage of communicative turns out of total number of opportunities; overall frequency of turns; novel semantic concepts

N=5 Paraprofessionals (European American - 2; European Canadian 3)

Individual Instruction; Storybook reading

Aided AAC modeling, Expectant delay, Wh- question asking; Contingent responding

KentWalsh, Binger, Ewing, Hickman & Quevedo (2008)

N = 5 11;1 (female) 7;8 (female) 7;9 (female)

Latino (2), African American (1), European American (2)

DD (2), CP (1)

SGD (3)

PPVT-III Standard Score Range: 40 - 66

Multi-modal communicative turns (Percentage); Communicative turns (Frequency); Novel semantic concepts (Frequency)

N = 5 Peers (European American - 3)

Individual Instruction; Storybook reading

Aided AAC modeling, Expectant delay, Wh- question asking, Contingent responding

KentWalsh, Binger and Hasham (2010)

N=6 8;0 (female) 5;4 (male) 5;0 (female) 8;3 (male) 4;7 (male) 5;11 (male)

African American (3), European American (3),

CP (3), DS (3)

Individual Instruction; Storybook reading

Aided AAC modeling, Expectant delay, Wh-question asking, Whquestion answering, Contingent responding

3;0 (male) 6;0 (male)

SGD (5), Picture Communication Symbols (1), Communication Boards (1) (One child used SGD + pic comm boards)

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PPVT-III Standard Score Range: 40-110 TACL3 Standard Score Range: 49-104

Multi-modal communicative turns (Frequency)

N=3 Graduate Speech-Language Pathology Student Clinicians (European American - 2) N = 6 Mothers: (African American - 3; European American - 3)

KentWalsh, Binger & Malani (2010)

N = 10 4;2 (female) 3;11 (male) 3;11 (male) 7;1 (male) 5;1 (male) 5;7 (female) 5;11 (male) 6;5 (female) 3;8 (male) 5;7 (male)

Not reported

Suspected CAS (4), ASD (2), ADHD (1), Congenital Myopathy (1), DS (3), CP (2), Unilateral Schizencephaly (1), Repaired Cleft Palate (1)

Low-Tech Communication Book (2), Manual Sign (7), Picture Symbols (4), SGD (10)

TACL-3 Standard Score/Age Equivalent Ranges: 51 106/ & 3;46;0

Multi-modal communicative turns (Frequency)

N = 10 Parents (Not Reported 9); Grandmother (Not Reported 1)

Group & Individual Instruction; Storybook reading

Aided AAC modeling, Expectant delay, Wh- question asking, Contingent responding, Verbal prompting

Rosa-Lugo & KentWalsh (2008)

N = 2 6;10 (female) 6;8 (male)

Latino (2)

Cystichygroma (1), DD (1)

SGD (2)

TACL-3 Standard Score Range: 64-66

Multi-modal communicative turns (Percentage); Communicative turns (Frequency); Novel semantic concepts (Frequency)

N = 2 Parents (Latino - 2)

Individual Instruction; Storybook reading

Aided AAC modeling, Expectant delay, Wh- question asking, contingent responding

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