2001 Conference Proceedings

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"NO PREREQUISITES"- THEORY INTO PRACTICE 

Jamie Judd-Wall, Executive Director
Kathleen King, Consultant
Technology and Inclusion 
Box 150878, Austin, TX 78715-0878 
Phone: voice/message: (512) 280-7235 
FAX: (512) 291-1113
Email: jamie@taicenter.com 
Web site: www.taicenter.com 

Abstract

Our center is a non-profit assistive technology training center in central Texas. We work with Medicaid waiver programs, school districts and rehabilitation programs. We refer to the folks we work with as clients. Our clients range in age from 3 years old to 55 years old, though in the past we have had clients who are younger and older. 

In our client training program we have put the 'no prerequisites' theory of VOCA use into practice in the AAC training program we will present. Based on research and culminating with a recent article series by Locke & Stagsetter, we have developed an augmentative communication training program which began with for individuals with autism and has expanded to include individuals with cortical blindness, traumatic brain injury and encaphalopathy. One hallmark of the training program is the immediate use of voice output devices. Our clients are talking from day one.


We use a highly a structured communication environment, individually designed motivational routines and the addition of a voice output device to a PECS like routine has resulted in significantly faster symbol learning, more frequent exchanges, and higher rates of initiation than training programs with symbol use alone. 
In 1998-99, we piloted the program with individuals with autism and mental retardation. In 1999-2000 we have expanded to include individuals with cortical blindness, traumatic brain injury and encaphalopathy Since our presentation last year, we have increased the number of individuals participating. To date, we have had measurable growth in over 100 individuals' communication abilities. Every person has shown improvement in communication abilities with decreased behavioral outbursts, increased initiation behaviors, increased meaningful use of symbols to communicate, increased communication topics and increased compliance. 

The training program is a five phase process. The traditional PECS strategies, the exchange of the picture symbol for the desired object, is enhanced through the use of voice output technologies. Early in the process, we use simple tools, such as the TechTalk (a digitized speech, battery operated portable communication device) or IntelliKeys (a programmable expanded keyboard for either Macintosh or Windows computers). Later in the training the equipment used moves to more sophisticated technology, such as dynamic display communication software and hardware, such as Speaking Dynamically Pro, and a touch screen such as the TouchWindow or a portable VOCA such as the Dynamo. 

Hallmarks of the training process include (1) the immediate use of voice out devices and (2) the early introduction of 'social commenting'. These serve two very important purposes: first our clients experience the increased partner attention and response rates that research shows us accompany the use of voice output devices and secondly they quickly move past basic needs to more normal conversational patterns. These conversation type exchanges invite the communication partner into a verbal exchange so that the focus of the process quickly moves from the exchange of items to the exchange of feelings and information. 


In Phase 1, the process is a simple expansion of the PECS training process. A velcro responsive base overlay is created for the device. Velcro hook fabric is attached to the picture (for our clients with cortical blindness we have created a set of tactile symbols.) The device is programmed with requests for the items as represented by the picture. As the picture is removed from the device and handed to the trainer, the request statement is made by the device.

As soon as the client is able to independently participate in the picture exchange, Phase 2 begins. He/she is moved to a dynamic display system. In this process, the picture is touched rather than removed and handed to the trainer. Upon touching the picture, the voiced request is made by the device and the desired item is provided (in VERY small quantities). Typically the desired item is food, although we frequently have students whose desired item is a physical interaction such as tickle or bounce. We routinely move the pictures on the screen to be sure that the student is actually attending to the content of the picture, not just randomly touching the screen.

In Phase 3, social comments are added to the training process. As the client requests the desired item, the display changes to an array of 2-5 social comments such as "This is fun", I'd like more please", and "Thank you" . In order to return to the screen with the food or play requests, the client needs to make a social comment. The screen then automatically returns to the set of desired options. Many clients will work on various sets of desired items at the Phase 3 level for quite some time. Clients at this phase are functional initiators of communication and interact well with their trainers. However they are not yet independently able to select communication topics or solve problems in the communication process.

In Phase 4, the client is taught how to select and switch between communication topics. Typically we will have clients who have 3-4 sets of desired requests with which they have been successful in past sessions. We then introduce the topic setters,a single board with snack, TV, computer games, and play time. As the client selects the topic setter, the screen changes to the familiar request set. The social comments page is fortified with termination statements such as "I'm finished", "That's enough" or "Let's do something different." The selection of a termination statement results in a return to the topic setting page. At the early stages of Phase 4 training client may return to the same topic area repeatedly as they familiarize themselves with the topic setting to requesting sequence. For many clients termination of an activity is an anxiety producing time and may cause unwanted behaviors. This extended practice in termination and initiation is an important learning time because it teaches the client how to end and begin desired activities. We have seen a substantial reduction in unwanted behaviors as clients overcome the anxieties of activity termination.


Finally in Phase 5, we add problem solving. What happens if you eat all of the most preferred food item ... or the batteries on the vibrating pillow wear out? How do you choose an alternate activity when the desired, but unavailable, activity is still visible on the choice board? What happens when you ask to eat but it's time to work? In traditional PECS the picture representing the unavailable option is removed from the set of items presented to the client. However, in electronic communication this means creating a new program every time some food is consumed or some toy is left on the bus... not a very reasonable option! In Phase 5 we add statements to the social comments page to reflect these situations. Comments such as "I ate it all", "It's all gone" and "What else can I eat/play with?", "It's time to work, lets get a snack when we're done." help clients learn that something can be visible on the choice set put not physically available. 
As you can imagine, many clients find these skill sets a challenging to master. The training is intense. Clients may spend long periods of time on a single comment, especially at the Phase 5 level. We have found that if we allow a client to express the desired thought, even if they need to say the same thing over and over, that we reduce unwanted behaviors, such as tantruming and self-injurious behaviors, almost to the point of extension.

Our successful expansion of the number of clients and range of disabilities served in the program continues to support our belief that our success can be replicated by others.

References:
Dynamo, Sentient Systems Technology, 2100 Wharton, Pittsburgh, PA 15203
IntelliKeys, IntelliPics, Overlay Maker by IntelliTools, 55 Leveroni Ct, Novato, CA
Speaking Dynamically, TechTalk by Mayer Johnson Co., Box 1579, Solana Beach, CA 
Touch Window by Edmark Corporation, Box 97021, Redmond, WA 

Peggy Locke & Mary Stagsetter, Bringing the World of Voice to Individuals with Severe Disabilities, parts 1-3 of 4, Closing the Gap, March-August 2000


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