AAC Framework: A resource to support device prescription

Important InformationThis is a framework to support clinical decision makingand to encourage a team approach for prescriptionof Speech Generating Devices (SGD’s).It should be used alongside:- Processes and resources that have been identifiedwithin your own organisation- Formal supervision and mentoring opportunitiesinternally and externally to your organisation-Next

How to ….?• This resource uses Powerpoint• It is divided into four parts• Introduction• Stage 1 - Information Gathering• Stage 2 - Trial and Goal Setting• Stage 3 - Evaluation and Decision Making• Users can enter the resource at each of these key stages, or view in a stepby step fashion by following the “NEXT” buttons• You must use the action button to navigate through, otherwise the orderwill be disrupted.• There are “jump off” buttons to and from documents with moreinformation. Either use BACK or close the open document that hasbeen hyperlinked.Next

Where to start?• Introduction, ICF Framework, Case Studyintroductions (next)• Assessment & Information Gathering• Trials and goal setting• Evaluation and Decision Making

The ICF FrameworkA holistic, biopsychosocial modelMore detailsNext

ICF InformationRecommended Reading• The World Health Organization’s International Classification of Functioning,Disability and Health: Implications for Clinical and Research Practice in the field ofAugmentative and Alternative Communication, P Rhagavendra, J Bornman, MGranlund and E Bjork-Akersson, Augmentative and Alternative Communication,December 2007• Towards an international framework for communication disorders: Use of the ICF,Travis T Threats, Journal of Communication Disorders, 2006• Making a World of Difference: The ICF-CY as a Tool for Building GlobalCommunities of AAC Providers, Sharon M. Rogers, ISAAC, Barcelona, Spain, July 27,2010. Retrieved from http://drsharonrogers.typepad.com/files/isaac-2010-makinga-world-of-difference-final-1.pptAdditional Reading• WHO International Classification of Functioning, Disability and Health• Information, training and resources. Retrieved fromhttp://www.who.int/classifications/icf/en/BackNext

ICF InformationAdditional Reading (cont’d)• Advances in Speech pathology, Volume 6, march 2004• Classifying communication disability using the ICF, T.T.Threats & L. Worrall• Where is the person in the ICF? J. Felson Duchan• Cautiously embracing the ICF, N. Simmons-Mackie• The ICF language of numeric adjectives, L. Boles• Speech pathologists’ application of the ICF to children with speechimpairment, S. McLeod• The ICF is all about the person, and more: A response to Duchan, Simmons-Mackie, Boles and McLeod• ICF: A guide to Assistive Technology Decision-making, Petra Karlsson. Retrievedfromhttp://www.arata.org.au/arataconf10/papers/KARLSSON_Petra_paper_arata10.doc• Framing AAC IEP Goals with ICF• http://mcn.educ.psu.edu/documents/Fried-Oken_Rowland_Lollar_Steiner_Framing_AAC_IEP_Goals_with_ICF_ASHA_2010.pdfNextBack

How will this framework help me and where do Istart?Prescription of a device is a very involvedprocess and can be quite a journey.Assessment &InformationGatheringIdentify trialoptions & setgoalsEvaluation /DecisionMakingNext

AlertThe purpose of using the ICF framework isto provide a ‘holistic’ and multifaceted viewto gather all information to support SGDprescription. This means that all elementsof the ICF are relevant and need to beconsidered and integratedBe sure to check out all components of the ICFNext

Guidelines for Considering Speech Generating Device (SGD) Options Based on the ICF(www.who.int)Health ConditionImpairment- Mentalfunctions/cognition- Diagnosis & Prognosis- Sensory (vision &hearing)-Neuromusculoskeletal(access)Activity- Communication- InterpersonalInteractions &relationships- Learning & applyingknowledge- Mobility (for portabilityof device)Participation- Home- Education- Community life- EmploymentEnvironment- Products & Technology- Best match, support & training- Attitude of family & othersPersonal Factors- Motivation- Attitude- Past experience and effectNext

Lifestages• It is important to look at what is happening for the client now,as well as their future needs.• Increased understanding of lifestages assists us to identifycommunication partners, communication functions, and theenvironments where communication is required for theindividual• Having an understanding of needs for now and later will helpyou to set realistic functional goals for meaningful outcomes• There a some resources that you can use to supportexploration of life-stagesMore detailsNext

Timetable for Growing Up“ Young people and their families go through many changes asthey grow up. The Growing Up Ready resources are designedto help children and youth with disabilities to get ready foradult life.”www.hollandbloorview.ca/resourcecentre/growing_up/documents/timetable.pdfParentingSocialSelf-CareEducationMedicalBack

Prescription Process3 key stages:• Assessment and information gathering• Trials & goal setting• Evaluation & decision makingAssessment &InformationGatheringIdentify trialoptions & setgoalsEvaluation /DecisionMakingNext

Guidelines for Considering Speech Generating Device (SGD) Options Based on the ICF (www.who.int)MarshaHealth ConditionOliverTaraImpairment- Mentalfunctions/cognition- Diagnosis & Prognosis- Sensory (vision &hearing)-Neuromusculoskeletal(access)Activity- Communication *- InterpersonalInteractions &relationships- Learning & applyingknowledge- Mobility (for portabilityof device)Participation- Home- Education- Community life- EmploymentJoEnvironmentProducts & Technology– Best match, support & training-Attitude of family & othersPersonal FactorsMotivationAttitudePast experience and effectCASE STUDIES – To be used asExamples ONLYNext

Marsha: a brief overview• Marsha • is 49 is 49 yrs yrs and and has has a diagnosis a of ofMND MND• Her • Her speech is becoming is dysarthric• She • She is keen is keen to to explore AAC AAC to to maintaincurrent levels of of communicationBack

.Tara : a brief overview• Tara is 5 yrs and has significantdevelopmental delays• It is a challenge to engage Tara, although sheresponds well to physical activity, by smilingBack

Oliver : a brief overview• Oliver is 12 yrs and has a diagnosis of ASD• He is a reluctant PECS user andcommunicates mainly using informalmethods• He will be transitioning to a new specialneeds unit at the end of the yearBack

Jo : a brief overview• Jo is 17 yrs and has cerebral palsy• His device needs replacing• He will be leaving school at the end of theyearBack

Stage 1: Assessment and Information GatheringAssessment &InformationGatheringIdentify trialoptions & setgoalsEvaluation /DecisionMakingBack to startNext

Principles to consider to support assessment:• Participation model• Dynamic assessment & Feature Matching• Team and collaboration• Natural settings• Training, mentoring, & support• Evidence based ethical practiceReferenced in Speech Pathology Australia, ‘Augmentative & AlternativeCommunication’ Clinical Guidelines, 2012Next

Assessment and information gathering• Consider all components of ICF framework• Impairment• Activity• Participation• Environment• Personal FactorsThe following ‘Prompt Questions’ will help you gatherinformation across all areas of the ICF: Domain Questions.pdfWho can help?Next

Who else can assist in the assessment process?Remember, as we are using the ICF framework and wanting aholistic view of the individual, we can gather information frommany professionals including:•Medical specialists•Family and other significant people in the person’s life•Teachers, teacher aides, and support workers•Allied Health Professionals – Occupational Therapist,Physiotherapist, Speech Pathologist, Social Worker•Assistive Technology assessment services (internal and /orexternal to organisation)•SuppliersNext

Impairment• Overall assessment of body structure andfunction, including cognitive function• Multidisciplinary• Consider diagnosis and prognosisNext

ImpairmentCognitiveSkillsSensorySkillsPhysicalStatusNext

Impairment: What do you need to know?• What is the person’s overall physical status?• What is the persons level of cognition and ability to learn?• Do they have an understanding of cause and effect?• Do they have an understanding of symbols – that one item can representanother?• If they understand symbols, what sort – objects, photos, line drawings,picture symbols, words/letters?• Memory capacity• Rate of learning?• Does the person have impairments in their vision or hearing?• What does their diagnosis tell you about the future?• Skills likely to develop further? Where to? - in short, medium and long term?• Skills likely to deteriorate?• Likely speed of change?Information gathering:• Become familiar with diagnosis and typical presentations.• Be aware of likely prognosisNext

How do we gather information regarding‘impairment’?• Access to medical records and allied healthreports• Comprehensive case history information• Use of checklists / resources as identified• Accessing further information from crediblesources e.g. Medical websites regarding‘diagnosis’ and ‘prognostic’ information.Next

Resources – ImpairmentRefer to Resource List:Resources for ICF Domains.pdfNext

Activity• Impact of physical, cognitive and/or sensoryimpairments on daily functioning• How does the person move their body to performactivities of daily living?• How do they use their vision and hearing?• What is their understanding of the world and howdo they interact with it e.g. behaviour,communication?Next

Activity: What do you need to know?• What is the person’s level of language and communication skills?• Pre-intentional, intentional• Emergent, context dependent, independent• What is their level of receptive language?• What sort of device will meet their needs – single message, sequencedmessage, multiple message (static display), multiple message (dynamicdisplay), text to speech• How will language be represented? Single meaning pictures (e.g. Gateway),multiple meaning pictures (e.g. Unity), words and letters• If using single meaning pictures, symbol set will be used e.g. PictureCommunication Symbols (PCS), Symbolstix etc• How will language be organised? Topic based, pragmatically, grammatically?• How will the person activate a device and mobilise within their environment?• Direct; direct with minor modifications (e.g.keyguard); direct with sophisticatedaccessories (e.g. headpointing, eye gaze); indirect etc• Will the device be carried or mounted?Next

Activity: What do you need to know?(contd)• How do any sensory impairments (e.g. Vision and hearing) impact onfunctioning?• Can the person see and discriminate between visual symbols? How many?• Do they need symbols to be enlarged? Do they need tactile symbols? Do theyneed auditory feedback?• How does the person’s cognitive status (as per prompt questions in Impairment)impact on the persons interaction and communication skills?• Do they have an understanding of symbols – that one item can representanother?• If they understand symbols, what sort – objects, photos, line drawings, picturesymbols, words/letters?• Information gathering• Work with colleagues to assess relevant physical, cognitive and sensory skills• Assess person’s language and communication skillsNext

SGD AccessAccess must be considered before investigatingSGD options.• Does the individual have an existing SGD and accessmethod?• Is the current access method reliable or does it requirereview by an Occupational Therapist?• If the individual is not using a SGD, can an accessmethod be identified from their upper limb functionor use of other technologies. This may require areview by an Occupational Therapist.Click here to find out more about - SGD AccessOptions.pdfNext

Impairment & Activity FactorsDevice suitable to meetcognitive, language andcommunication needs todayand in future.Features to meet vision andhearing needs.Access method andtransportation – which maychange as skills develop ordeteriorateNext

Gathering Activity Information• Multidisciplinary• Access skills• Language and communication skillsSpecific Assessment Examples (Next)• Resources: Resources for OCF Domains.pdfBest Practise Guidelines require the involvement of amultidisciplinary team including SLP’s, OT’s, PT’s and others,as relevantNext

Assessing language and communication skills• Young child• Child• Teen• Young adult• AdultNext

Young Child – Communication AssessmentsEmergentContextdependentIndependentCommunicationMatrixPragmatic ProfileInventory of PotentialCommunication Acts(IPCA)StandardisedAssessments e.g. PreVerbal CommunicationAssessment , Rosetti,REEL, McArthur ScalesStandardisedAssessments e.g. PLS,CELF-Preschool,BackAssessment details

Child – Communication AssessmentsEmergentContextdependentIndependentCommunicationMatrixPragmatic ProfileInventory of PotentialCommunication Acts(IPCA)Standardised Assessmentse.g. Pre VerbalCommunicationAssessment ,Standardised Assessmentse.g. PLS, CELF, CASLBackAssessment details

Teen – Communication AssessmentsEmergentContextdependentIndependentPragmatic ProfileInventory of PotentialCommunication Acts(IPCA)Standardised Assessmentse.g. Pre VerbalCommunicationAssessment ,Standardised Assessmentse.g. CELF, CASLBackAssessment details

Young Adult – Communication AssessmentsEmergentContextdependentIndependentPragmatic profileStandardAssessments e.g.Triple C ChecklistStandardAssessments e.g.CELFStandardAssessments e.g.BackAssessment details

Adult – Communication AssessmentsEmergentContextdependentIndependentPragmatic ProfileStandard Assessmentse.g. Triple C ChecklistStandard Assessmentse.g.BDAE, PALPA, WAB,Frenchay DysarthriaAssessmentBackAssessment details

Assessment detailsThis is a list of commonly used assessments and it is acknowledged that otheroptions exist. We encourage you to review details and application of assessmentsthat are unfamiliar to you. Links are provided for ‘known’ online resources.Refer to Resource List:Resources for ICF Domains.pdfBack to:Young ChildChildTeenYoung AdultAdultNext

Participation• How the person uses their skills and abilities to participatein life - at home, school, work• What does the person do or need to do, to participate tothe best of their ability in these environments?• What are the facilitators and barriers to participation?Next

Participation: What do you need to know?• What activities is the person engaged in? Daily, regularly, occasionally?• What will the person want or need to communicate in these differentsituations?• Will the device have the language/vocabulary to meet these needs?• Can the device expand to meet new and changing needs?• Will the device be practical in all settings? e.g. size, weight, durability,volume of speech output• Can it be easily moved, mounted?Information gathering:• Talk to person, their family, teachers, support workers, carers etc, to ensurethe device will have the features, settings and vocabulary to allow theperson to communicate to their maximum potential• Discuss and problem solve any practical issuesNext

Adding Participation Factors to the Mix…Participation factorsDevice that hasthe capacity tomeet needs in avariety ofsituations andwith a variety ofpeopleImpairment & activity factorsDevice that theperson can useefficiently andeffectively, withthe mostappropriate meansof representinglanguageNext

Participation resourcesRefer to Resource List:Resources for ICF Domains.pdfNext

Environment•What aspects of the person’s environmentfacilitate activity and participation?•What aspects of a person’s environment arebarriers to activity and participation?Next

Environment: What you need to know• Who is in the persons’ circle of support?• Who will ensure the person using the device is given every opportunity to participate?• Who will teach the person to use their device to their maximum potential?• Who will add vocabulary and keep the device relevant to the persons needs?• Who will support device use in terms of the following:• Charging batteries?• Set up of any additional accessing equipment?• Troubleshooting operational issues?• Back up of individual programming and general maintenance?• Will there be major changes in the person’s situation? Transition to school, high school, TAFE,work etc? Who will facilitate this transition in terms of device support?• Will it integrate with other technologies?• Will there be financial issues?Information gathering:• Ensure support team is willing and prepared to support the implementation of a device• Discuss training needs, as necessary• Discuss practical issues of integration of technology, support and maintenance to determinefacilitators and barriers• Identification of key stakeholders if transition is imminent• Exploration of funding optionsNext

Adding Environment Factors to the Mix ...EnvironmentfactorsDevice that is accepted,practical, supportable andaffordable in theenvironmentParticipationfactorsDevice that has thecapacity to meet needsin a variety ofsituations and with avariety of peopleImpairment &Activity factorsDevice that the personcan use efficiently andeffectively, with themost appropriatemeans of representinglanguageNext

Refer to Resource List:Environment resourcesResources for ICF Domains.pdfNext

Personal Factors• Factors related to personality, preferences,past experiences etc• The things that make us unique and individualNext

Personal Factors: What you need to know• How well do you know the person?• What is the persons level of motivation to learn/use a device?• What are their previous experiences with an AAC system/device?• What are their preferences in terms of device type, aesthetics etcInformation gathering:• Talk to the person, their family and close support team• Involve them in the decision making process• Always try to offer an opportunity for informed choice• Take their thoughts and preferences seriously and try to accommodatewherever possibleNext

Adding Personal Factors to the Mix ...EnvironmentfactorsDevice that is accepted,practical and supportable inthe environmentPersonal factorsDevice that ispreferred by thepersonParticipationfactorsImpairment &Activity factorsDevice that theperson can useefficiently andeffectively, withthe mostappropriatemeans ofrepresentinglanguageDevice that has the languagecapacity to meet needs in avariety of situations and with avariety of peopleNext

Personal factors resourcesRefer to Resource List:Resources for ICF Domains.pdfNext

Four Case StudiesAssessment and Information GatheringMarshaTaraOliverJoForward to Stage 2: Trial Options and Goal Setting

Health ConditionMotor Neurone Disease(progressive)Marsha, 49 yrsImpairmentAmyotrophic lateral sclerosisWeakness / atrophy in legs,arms and oral motormusculatureNo evidence of cognitivedeclineActivityMobilises in wheelchairADL’s slow and fatiguingSpeech becoming dysarthric –speech slurred, shallowbreathingRegular coughing whilst eatingand drinkingParticipationLives aloneModified work dutiesAttends church with assistanceBecoming less socially activePersonal FactorsFiercely independentTechnology savvyEnvironmentAware of communicationtechnologyMay not be eligible for fundingOver-protective parents(elderly)Back to Case StudiesAssessment

Assessment and Information Gathering• Refer back to Key Stage 1• Gather information in all domains of ICF• Involve the client, their family and key supportpeople in their network• Involve professional colleaguesNext

Let’s Look at Marsha through ICF eyes .....The ICF Prompt Questions have been applied toMarsha, to provide more information to supportyour assessment and information gathering. Clickhere to understand more about Impairment,Activity, Participation, Environment, & PersonalFactors ICF Domain Questions Marsha.pdfNext

ImpairmentDevice with alternativeaccess options shouldthese become necessaryContemporary designwith access to socialmediaPersonalFactorsMarshaActivityText to speech +rate enhancementAble to be supported byfriends and family ifMarsha becomes unableto do soEnvironmentParticipationKeyboard vtouchscreen? -unknownAffordable (if funding notavailable)Easily moved andrepositionedWhich device? Potential candidates for trial:Lightwriter SL40, Dynawrite, iPad with Predictable, Smart II, Nova Chat 7/11?Back to case studies

Health ConditionDevelopmental DelayTara, 5 yrsImpairmentLearning difficultiesSensory and attentionchallengesDecreased oral motordifficulties - ++ saliva lossActivityMobilises by crawling and can pull selfup on furnitureWill reach for desired play objectssymbolic play developingVocalises and some simple gesturesduring interactionsParticipationEnrolled for mainstream prep nextyearCurrently attend Kindy 5 days/wkGoes to a play gym with youngersiblingEnvironmentSingle Mum who is ++ busyOnly child with complexcommunication needs in kindy(has teacher aide support)Personal FactorsVery active childLikes exploring her ownenvironment and engaging innew thingsNext

Assessment and Information Gathering• Refer back to Key Stage 1• Gather information in all domains of ICF• Involve the client, their family and key supportpeople in their network• Involve professional colleaguesNext

Let’s Look at Tara through ICF eyes .....The ICF Prompt Questions have been applied toTara, to provide more information to support yourassessment and information gathering. Click hereto understand more about Impairment, Activity,Participation, Environment, & Personal Factors ICFDomain Questions Tara.pdfNext

Support for Mum tosatisfy her that simple,static devices are themost appropriate, at thisstageCapable of being used insituations that motivate Tarae.g playgroundactivities/environmentInvestigate staff supportneeds in current andfuture placementsPersonalFactorsConsider implications ofproducing/providing symbolrepresentations e.g. objects ofreference, symbol producing programs(i.e. Boardmaker)EnvironmentImpairmentTaraLarge target area initially toaccommodate gross motorskillsParticipationActivityWhich device? Potential candidates for trial:Big Mack, 4 Compartment Communicator,Cheap Talk 8 with switch jacks, TechTalk, SupertalkerBack to case studiesFlexibility ofsymbolrepresentation –3D, 2DConsolidation ofcause/effectunderstanding (1 message)with capacity to increaseas skills developEasily moved andrepositioned toaccommodate behaviour

Oliver, 12yrsHealth ConditionAutism Spectrum DisorderImpairmentSome fine motor planningdifficultiesCognitive delaysVisual-perceptual difficultiesActivityIndependently mobileHas some understanding of picturesymbols (PCS) to represent languageAppears to learn best in structured,naturalistic settings and within ownareas of interestParticipationRequires special educationalprogramParticipation dependent onothers to engage him in activityPredominance of requestingand directingbehaviour/communicationEnvironmentLives with parents and 2 siblings, 1 with ASDalsoBoth parents unemployedLittle extended family supportPersonal FactorsVery interested in all kinds of transport – cars,trucks, trains etcNeeds large personal space separationParticularly attached to younger sister (withoutdisability)Next

Assessment and Information Gathering• Refer back to Key Stage 1• Gather information in all domains of ICF• Involve the client, their family and key supportpeople in their network• Involve professional colleaguesNext

Let’s Look at Oliver through ICF eyes .....The ICF Prompt Questions have been applied toOliver, to provide more information to supportyour assessment and information gathering. Clickhere to understand more about Impairment,Activity, Participation, Environment, & PersonalFactors ICF Domain Questions Oliver.pdfNext

Has not been motivated byindividual symbol cards(static) used in PECS programSuccess will be highlydependent on finding adevice that motivates OliverSupport for family who may havelimited capacity to implementdevice. Focus on sister?Implementation of device mayassist to change staff attitudes toOliver's potential. Need toinvestigate support needs incurrent and future placementsConsider implications of producingsymbol representations if staticdisplay device chosen e.g.BoardmakerPersonalFactorsEnvironmentImpairmentOliverParticipationDisplay appearance (static v dynamic)and cell size yet to be determined andneeds to meet both physical and visualperceptual needsActivityWhich device? Potential candidates for trial:SmartSpeak, Tobii S32, Dynavox M3, Nova Chat 7/11?Back to case studiesStatic v dynamic style yet tobe determined – need tobalance learning needs,language andcommunication needs andpossible preference fordynamic displayLearning activities need to behighly structured + motivating toensure understanding andmeaningful use of deviceMust be easilytransportable for OliverMust be robust to withstandheavy handling

Jo, 17 yrsHealth ConditionCerebral Palsy (SpasticQuadriplegia)ImpairmentCP affecting all 4 limbs (stiff /tightness)Increased stiffness / changes inhead movements recentlyHealth deteriorating – chestinfectionsActivityMobilises independently in poweredmobilityProficient communicator currently usingPathfinder SGD (head access with switchand scanning)ParticipationCurrently lives with parents and 1siblingRelationships with wide range ofpeopleAttends mainstream high school withsupportPlanning to go to TAFE for furthereducationEnvironmentPlanning to move out of homePersonal FactorsHaving access to ‘new’ technology isimportantDetermination for independenceNext

Assessment and Information Gathering• Refer back to Key Stage 1• Gather information in all domains of ICF• Involve the client, their family and key supportpeople in their network• Involve professional colleaguesNext

Let’s Look at Jo through ICF eyes .....The ICF Prompt Questions have been applied toJo, to provide more information to support yourassessment and information gathering. Click hereto understand more about Impairment, Activity,Participation, Environment, & Personal Factors ICFDomain Questions Jo.pdfNext

Which device? Potential candidates for trial:Eco2, Vantage Lite or Accent? (after othernon-unity device options explored with Jo)ImpairmentDevices with multiple accessoptions to explore alternativesto head mounted switchAbility for youngerpeople in Jo’s circleof support to engagemore readily and ageappropriatelyPersonalFactorsJoActivityUnity based deviceto retain priorlearning andgenerative system –Jo’s preferenceCost – can fundingbe obtained?Transition to TAFE.Establish training needsEnvironmentParticipationUnity device that ismore mainstreamand can integratewith othertechnologyMounting options mayneed to be considered ifaccess method changesBack to case studiesNext (stage 2 )

Stage 2 : Trial Options & Goal SettingAssessment&InformationGatheringIdentify trialoptions &set goalsEvaluation /DecisionMakingBack to startNext

Trials & GoalsThere are many options out there to trial withclients. The best trials will be using theinformation you have gathered in the first stepusing the ICF framework and thinking aboutthe current and future life stages for theperson. Remember, we want to findsomething that will support the client for atleast 5 years.Next

The Trial CycleDuring the trial, we want to see outcomes in as many areas as possible acrossthe ICF. You can think of this as a cycle, ticking off the areas as you trial thedevice. A successful trial will have most if not all categories ticked.ImpairmentPersonalFactorsActivityEnvironmentParticipationNext

.The Trial ProcessThe following Trials will take time and should bebased on functional goals that you want toachieve during the trialeps can be followed:1. Determine 2-3 options of SGD’s2. Trial each option with the client (minimum of2 weeks), establishing baseline skills andgoals to be achieved during the trialNext

Options to TrialChoose SGD’s that appear to be the ‘Best-Fit’ according to theinformation you have gathered for the client. You will need totrial each option to determine the ‘actual’ fit and gatherinformation from the client and significant others.Remember, you are aiming for something that:• Allows the person to communicate a range of communicationfunctions• Can be used with familiar and unfamiliar communicationpartners• Can be used and supported across different environmentsSGD Options Prompt Questions.pdfNext

Go to points for different Speech GeneratingDevices:The following SGD distributors have interactive websites whereyou can search for SGD options to see and gather moreinformation:• Spectronics - www.spectronicsinoz.com• Zyteq - www.zyteq.com.au• Liberator – www.liberator.net.au• Link AT – www.linkassistive.com• CommunicATe – www.communicateat.com.au(NB. This is not an entire list and therapists are encouraged tosource all options)Next

The TrialDuring each trial, it can be useful to:1. Determine baseline skills for using the device2. Establish goals to be achieved3. Measure outcomes from the goals setNext

Determining Baseline SkillsYou will need to have a good understanding ofthe person’s initial abilities and skills with thedevice, and how this fits in with theirenvironment. The following template maysupport gathering of this information, basedon Janice Light’s model of ‘CommunicativeCompetence’ (1989):Device Trial Baseline Proforma.pdfNext

Goal Setting – General Principles• Client and family focused• Focus on functional outcomes in Activity andParticipation domains of ICF, with considerationof other ICF components• Consider Activities and Participation in multipleenvironments.• Information gathered from the ‘BaselineProforma’ may assist to develop specific shortterm goals during the trialNext

What is a Goal?A goal should be a simple statement that outlines the desiredoutcome to be achieved:Condition Action How measured?Child example:When given a VmaxdeviceAdult example:With a LightwriterTom will greet hispeersBob will request hismorning tea at a localcafeEvery morning duringcircle time at schoolAt least once a weekReference: ‘PRC Transitioning Toolkit’Next

Resources to Support Goal Setting• Special Education Technology (SET) – BritishColumbia at www.setbc.org (based oncommunicative competence and different levels ofdependence / independence• Rocky Bay ‘Information Kit for AAC Teams’ –www.rockybay.org.au /go/services/clinical-servicesdirectorate/resources/information-kit-for-aac-teams• SETT Framework by Joy Zabala atwww.joyzabala.comNext

Measuring Outcomes from the Goals SetThe following tools are useful to formaliseoutcomes of the goals set for trial:• Goal Attainment Scale (GAS) (Kiresuk &Sherman, 1968)• Canadian Occupation Performance Measure(COPM)• Qualitative Information about when thedevice was used, who with, and what for (youcan keep this documentation during the trial).Next

Four Case StudiesTrial Options and Goal settingMarshaTaraOliverJoBack to trial options and goal settingForward to Evaluation and decision making

ScoreBaseline(skill level at start oftrial)-2Less than expectedoutcome-1Expected outcome0Example Goal for Marsha - 1Attainment Level / OutcomeUsing a text to speech device, Marsha constructs a full message withregular spelling errors, slow speed ( >6 mins) and some effort.Using a text to speech device, Marsha will construct a full message withregular spelling errors, slow speed (>4 – 6 mins) and some effort.Using a text to speech device, Marsha will construct a full message withregular spelling errors, regular speed (>2 - 4 mins) without effort.Greater thanexpected outcome+1Much greater thanexpected outcome+2Using a text to speech device, Marsha will construct a full message withminimal spelling errors, adequate speed (>0 - 2 mins) without effort.Using a text to speech device, Marsha will construct a full message with nospelling errors, adequate speed (>0 - 2 mins) without effort.Next

ScoreBaseline(skill level atstart of trial)-2Less thanexpectedoutcome-1Expectedoutcome0Example Goal for Marsha - 2Attainment Level / OutcomeMarsha does not have access to a Speech Generating Device which integratescommunication and social media functions in a sleek design.Marsha does have access to a Speech Generating Device, however there is notintegration of communication and social media functions within a sleek design.Marsha has access to a Speech Generating Device which integratescommunication and social media functions in a sleek design, and she issome what happy with the choice.Greater thanexpectedoutcome+1Much greaterthan expectedoutcome+2Marsha has access to a Speech Generating Device which integratescommunication and social media functions in a sleek design, and she ismoderately happy with the choice.Marsha has access to a Speech Generating Device which integratescommunication and social media functions in a sleek design, and she is ecstaticwith the choice.Next

Trial InformationLightwriterSL40DynawriteiPad with textto speechiAppSmart IINovaChat7 or 10ALL: Spelling keyboards, displays, rate enhancement features e.g. word prediction,portable+ve•Simple,intuitive•Keyboardcapitalises ontyping skills•Keyguardsavailable+ve• Simple,intuitive•Keyboardcapitalises ontyping skills•Keyguardsavailable•Switch andscanning+ve•Sleek,mainstreamdesign•Access to emailand social media•Switch accessmay be availablewith additionalinterface (iAppspecific)+ve•Very smalland portable•Switch andscanning+ve•Sleek, mainstreamdesign•Access to email andsocial media•Switch and scanning-ve•No alternativeaccess options•No access toemail, socialmedia-ve•No access toemail, socialmedia-ve•Volume – mayneed additionalspeakers - ? easeof portability•Access does notmake use oftyping skills-ve•Access doesnot make useof typingskills•No keyguards•No access toemail, socialmedia-ve•Access does not makeuse of typing skillsBack

Example Goal for Tara - 1ScoreBaseline(skill level at start oftrial)-2Less than expectedoutcome-1Expected outcome0Attainment Level / OutcomeGiven a static simple communication device, Tara will lift up her sipper cup and shake it toindicate that she want ‘more drink’, to communicate a basic need/want.Given a static simple communication device, Tara will lift up her sipper cup and shake it toindicate that she want ‘more drink’, and with visual and verbal requests will attend to modellingof a choice between two high contrast symbols on the device to communicate a basicneed/want.Given a static simple communication device, Tara will attempt to request that shewants a drink by choosing a high contrast symbol from a choice of two on the device,with 50% accuracy to communicate a basic need/want.Greater than expectedoutcome+1Much greater thanexpected outcome+2Given a static simple communication device, Tara will attempt to request that she wants adrink by choosing a high contrast symbol from a choice of two on the device, between 50%and 75% accuracy to communicate a basic need/want.Given a static simple communication device, Tara will attempt to request that she wants adrink by choosing a high contrast symbol from a choice of two on the device, between 75%and 100% accuracy to communicate a basic need/want.Next

ScoreBaseline(skill level at start oftrial)-2Less than expectedoutcome-1Expected outcome0Greater thanexpected outcome+1Much greater thanexpected outcome+2Example Goal for Tara - 2Attainment Level / OutcomeTara’s Kindy teacher does not use a Speech Generating Device to modellanguage in any activities across the school day.Tara’s Kindy Teacher uses a Speech Generating Device to model language in amotivating activity for Tara on one occasion across the school day.Tara’s Kindy Teacher uses a Speech Generating Device to model languagein a motivating activity for Tara on two occasions across the school day.Tara’s Kindy Teacher uses a Speech Generating Device to model language in amotivating activity for Tara on three occasions across the school day.Tara’s Kindy Teacher uses a Speech Generating Device to model language in amotivating activity for Tara on four occasions across the school day.Next

Trial InformationLarge target, singlemessage device e.g. BigMackCompartmentaliseddevice e.g. 4compartmentcommunicatorFixed static display withswitch jacks e.g.Cheaptalk 8 withexternal jacks (4)Fixed static display withtwo rows of cellsFlexible static displaywith switch jacks e.g.Supertalker+ve•Simple, intuitive•Large target area•Can be placed next toobject referent to developsymbolic understanding•Potential to transition to2D symbols•Easy to position andreposition+ve• Objects and 2D symbolscan be introducedtogether•1 – 4 choices dependingon device•Large target area+ve•Can start with externalswitches as target andtransition to keyboard•Devices can offer 1 – 8choices•Multiple levels forstorage of vocabulary+ve•Can place objects ofreference on top row,initially, untilunderstanding of 2Dsymbols is established• Device can offer 1 – 8large target choices•Multiple levels forstorage of vocabulary+ve•Use external switches astarget and transition tokeyboard•Keyboard can be resizedand fully utilised with anylayout•Keyboard target size willreduce gradually as moreoptions incorporated•Models can offer 1 – 8choices•Multiple levels forstorage of vocabulary-ve•Vocab selectionresponsibility of team•Restrictive – no room forgrowth•Need to produce symbolreferents-ve•Vocab selectionresponsibility of team•Limited room for growth•Bulky•Need to produce symbolreferents-ve•Vocab selectionresponsibility of team•Not as easy toincorporate 3D objects•Cell size fixed•Unwanted cells will beleft empty – distracting?•Need to produce symbolreferents•? Durability to cope withaccess method•Transportation? – leadsand individual switches-ve•Vocab selectionresponsibility of team•Cell size fixed•Unwanted cells will beleft empty – distracting?•? Durability to cope withaccess method•Need to produce symbolreferents-ve•Vocab selectionresponsibility of team•Not as easy toincorporate 3D objects•? Durability to cope withaccess method•Need to produce symbolreferents•Transportation? – leadsand individual switchesBack to case studies

ScoreBaseline(skill level at start oftrial)-2Less than expectedoutcome-1Expected outcome0Greater than expectedoutcome+1Much greater thanexpected outcome+2Example Goal for Oliver - 1Attainment Level / OutcomeOliver attends to modelling of a two cell combination (e.g. “I want .....) on a speech generatingdevice to communicate a need/request for a favourite activity, with visual and verbal prompts.Oliver attends to modelling of a two cell combination (e.g. “I want .....) on a speech generatingdevice to communicate a need/request for a favourite activity, without the need for visual andverbal prompts.Oliver attends to modelling of a two cell combination (e.g. “I want .....) on a speech generatingdevice to communicate a need/request for a favourite activity, without visual and verbalprompts, and will randomly select one cell on a page to express a need / want after prompting.Oliver attends to modelling of a two cell combination (e.g. “I want .....) on a speech generatingdevice to communicate a need/request for a favourite activity, without visual and verbalprompts, and will purposely select one cell on a page to express a need / want after promptingwith less than 50% accuracy.Oliver attends to modelling of a two cell combination (e.g. “I want .....) on a speech generatingdevice to communicate a need/request for a favourite activity, without visual and verbalprompts, and will purposely select one cell on a page to express a need / want after promptingwith less than 50% accuracy.Next

Example Goal for Oliver - 2ScoreBaseline(skill level at start oftrial)-2Less than expectedoutcome-1Expected outcome0Attainment Level / OutcomeOliver does not attend to a Speech generating Device and is not motivated when promptedto interact with the device.Oliver attends to a Speech Generating Device when prompted with some motivation.Oliver accesses a Speech Generating Device with motivation and independence onat least one occasion during the day.Greater than expectedoutcome+1Oliver accesses a Speech Generating Device with motivation and independence on twooccasions during the day.Much greater thanexpected outcome+2Oliver accesses a Speech Generating Device with motivation and independence on three ormore occasions during the day.Next

Trial InformationFixed static display e.g.Tech/SpeakFlexible static display e.g TobiiS32Dynamic display with digitisedvoice e.g. Dynavox M3Dynamic display with synthesisedvoice e.g. Nova Chat 7/ 11+ve•Static display may be visually easierthan dynamic•Choice of 2D symbols and colour –photos, PCS, line drawings, blackand white, high contrast etc•Devices can offer up to 32 choices+ storage in levels (2,4,6,12)•Static display – may assist to keepOliver focused as no easy access toother vocabulary•May tolerate more heavy handling+ve•Static display may be visually easierthan dynamic•SymbolMate software offersSymbolStix•Keyboard can be resized and fullyutilised with any layout•Keyboard target size will reducegradually as more optionsincorporated•Can offer 1 – 32 choices + storageon 192 levels•Static display – may assist to keepOliver focused as no easy access toother vocabulary•May tolerate more heavy handling+ve•No requirement to produce overlays•Pre-programmed vocabularyincluding visual scenes in somedevice•PCS symbol library•Independent access to newvocabulary through page linkingfeature+ve•No requirement to produce overlays•Pre-programmed vocabularyincluding visual scenes in somedevices•PCS and SymbolStix library•Independent access to newvocabulary through page linkingfeature•Synthesised output will support anyemergent literacy skills-ve•Cell size fixed•Unwanted cells will be left empty –distracting?•Need to produce symbol referents –Boardmaker?•independent access to newvocabulary may not be possible-ve•PCS symbol set not available•independent access to newvocabulary may not be possible-ve•Appearance of dynamic screen maynot suit visual needs• Independent access to vocabularymay be too complex and/ordistracting•Access – too gross for delicatetouchscreen?-ve•Appearance of dynamic screen maynot suit visual needs• Independent access to vocabularymay be too complex and/ordistracting•Access – too gross for delicatetouchscreen?Back to case studies

ScoreBaseline(skill level at start oftrial)-2Less than expectedoutcome-1Example Goal for Jo - 1Attainment Level / OutcomeGiven a unity based device, Jo constructs sentences relating to needs and wants, but doesnot have access to vocabulary relating to ‘teenage’ related topics, and rarely initiatesconversation with his peers.Given a unity based device, Jo constructs sentences relating to needs and wants, and workswith a support person to program his device so that he has access to language related‘teenage’ topics, but rarely initiates conversation with his peers.Expected outcome0Given a unity based device, Jo constructs sentences relating to needs and wants. He hasaccess to language related ‘teenage’ topics, and initiates a conversation with his peers usingthis language once daily.Greater than expectedoutcome+1Given a unity based device, Jo constructs sentences relating to needs and wants. He hasaccess to language related ‘teenage’ topics, and initiates a conversation with his peers usingthis language twice daily.Much greater thanexpected outcome+2Given a unity based device, Jo constructs sentences relating to needs and wants. He hasaccess to language related ‘teenage’ topics, and initiates a conversation with his peers usingthis language more than 2 times each day.Next

Example Goal for Jo - 2ScoreBaseline(skill level at start oftrial)-2Less than expectedoutcome-1Attainment Level / OutcomeJo does not use use eye gaze for access to construct messages on a Speech GeneratingDevice.Jo uses eye gaze to construct messages on a Speech Generating Device between 0%-50%of occasions.Expected outcome0Jo uses eye gaze to construct messages on a Speech Generating Device between50%-75% of occasions.Greater than expectedoutcome+1Jo uses eye gaze to construct messages on a Speech Generating Device between 75%-100% of occasions.Much greater thanexpected outcome+2Jo uses eye gaze to construct messages on a Speech Generating Device on100% ofoccasions.Next

Trial InformationEco 2 Vantage Lite Accent+ve•Capitalises on prior learning of Unity system,including 144 icon page set•Language system familiar to school staff•Windows 7 computer•Large screen – 35.8 cm•Multiple access options including eye gazewith EcoPoint accessory, integratedheadpointing•Ability to integrate with computer for otherfunctions – educational, email, internet(additional Bluetooth accessories required)•IR for environmental control-ve•Size of screen for eye gaze not favoured byJo•Some difficulty calibrating eye gaze foraccess•Larger device potentially heavier and moredifficult to mount for eye gaze access+ve•Capitalises on prior learning of Unity system•Language system familiar to school staff•Screen size – 21.3 cm•Multiple access options includingheadpointing with Tracker Pro•Integrated Bluetooth connectivity•IR for environmental control-ve•Access via integrated headpointing systemnot efficient for Jo – too fatiguing•No eye gaze option•Maximum 84 icon Unity page set+ve•Capitalises on prior learning of Unity system,including 144 icon page set•Language system familiar to school staff•Windows 7 computer – sleek new design•Screen size – 29.5 cm•Multiple access options including eye gaze withNuEye accessory•Headpointing via additional accessories•Screen size favoured by Jo•Ability to integrate with computer for otherfunctions – educational, email, internet (additionalBluetooth accessories required)•Front and rear camera•IR for environmental control•Smaller and lighter to mount for eye gaze access•More interest shown in this device by peers-ve•No limitations – favoured device by JoBack to case studiesNext (Stage 3)

Stage 3 :Evaluation & Decision MakingAssessment &InformationGatheringIdentify trialoptions & setgoalsEvaluation /DecisionMakingBack to startNext

Evaluation & Decision MakingYou are at the final step following thorough trialof a number of possible devices for your client. Incollaboration with the client and their supports,you are to decide on the device that:- Caters for impairment, activity and participation,environment, and personal factors- Will meet their current and future needsNext

Reflection on the Trial CycleRemember, we want to see outcomes in as many areas as possible across theICF. Can you tick most of these areas if not all?Which device wasmost preferred?ImpairmentWhich device best met the personsphysical, sensory and cognitive needs?Which device wasthe best fit for theenvironment andthe people whowill support thedevice?PersonalFactorsEnvironmentParticipationActivityWhich device providedthe person with thebest access tolanguage?Which device allowed theperson to function best athome, work, school etc?Next

Four Case StudiesEvaluation and Decision MakingMarshaTaraOliverJoBack to Evaluation and Decision MakingNext

Reflection on the Trial CycleMarshaImpairmentWhich device best met the personsphysical, sensory and cognitive needs?Which device wasmost preferred?Which device wasthe best fit for theenvironment andthe people whowill support thedevice?PersonalFactorsEnvironmentParticipationActivityWhich device providedthe person with thebest access tolanguage?Which device allowed theperson to function best athome, work, school etc?Next

Decision Making FrameworkTrials of iPad, Dynawrite and NovaChat 7It is important to compare the success of thetrial of each system and how it best meetsneeds across the different ICF Domains. Clickhere to see comparisons for Marsha’s trials:Decision Making Framework for Marsha.pdfNext

Reflection on the Trial CycleTaraWhich device wasmost preferred?ImpairmentWhich device best met the personsphysical, sensory and cognitive needs?Which device wasthe best fit for theenvironment andthe people whowill support thedevice?PersonalFactorsEnvironmentParticipationActivityWhich device providedthe person with thebest access tolanguage?Which device allowed theperson to function best athome, work, school etc?Next

Decision Making FrameworkTrial of Big Mack x 2 and 4 Compartment CommunicatorIt is important to compare the success of thetrial of each system and how it best meetsneeds across the different ICF Domains. Clickhere to see comparisons for Tara’s trials:Decision Making Framework for Tara.pdfNext

Reflection on the Trial CycleOliverImpairmentWhich device best met the personsphysical, sensory and cognitive needs?Which device wasmost preferred?Which device wasthe best fit for theenvironment andthe people whowill support thedevice?PersonalFactorsEnvironmentParticipationActivityWhich device providedthe person with thebest access tolanguage?Which device allowed theperson to function best athome, work, school etc?Next

Decision Making FrameworkTrials of Tobii S32, Dynavox M3 and NovaChat 7It is important to compare the success of thetrial of each system and how it best meetsneeds across the different ICF Domains. Clickhere to see comparisons for Oliver’s trials:Decision Making Framework for Oliver.pdfNext

Reflection on the Trial CycleJoImpairmentWhich device best met the personsphysical, sensory and cognitive needs?Which device wasmost preferred?Which device wasthe best fit for theenvironment andthe people whowill support thedevice?PersonalFactorsEnvironmentParticipationActivityWhich device providedthe person with thebest access tolanguage?Which device allowed theperson to function best athome, work, school etc?Next

Decision Making FrameworkTrials of Eco2, Vantage Lite, Accent 1200It is important to compare the success of thetrial of each system and how it best meetsneeds across the different ICF Domains. Clickhere to see comparisons for Jo’s trials:Decision Making Framework for Jo.pdfNext

Device PrescriptionYou are now ready to prescribe a device. There are anumber of option:- Personal / family contributions- Local community support / funding e.g. Lions Club,Rotary- Government - In Queensland support may beprovided financially through Medical Aids SubsidyScheme – www.health.qld.gov.au/mass/(You will need to go to this website to establish eligibilityand ‘Communication Aids’ process.)Next

MASS forms for ‘Communication Aids’You will need to download and complete thefollowing forms:• MASS 21 Communication Aids ApplicationForm, &• MASS 21 App SGD Speech Generating DeviceApplication Form AppendixOr MASS 21 App CS Communication SoftwareApplication Form AppendixNext

Four Case StudiesWhere are they now?MarshaTaraOliverJoNext

Marsha – Where is she now?• Marsha initially showed a preference for the iPad with Predictable,although this was partially driven by cost – not eligible for MASS at thattime• Subsequently, Marsha’s condition deteriorated suddenly. She gave upwork and became eligible for MASS funding.• Trails of the Dynawrite and NovaChat 7 were completed:• Both had alternative access options to meet future needs• Different direct access methods – 2 finger typing (Dynawrite) versusindex finger pointing (NovaChat 7) Quicker with typing but more tiringthan pointing• Design of NovaChat 7 with integrated speakers preferredNova Chat 7Next

Marsha (contd)• Marsha’s MASS application was successful and she tookdelivery of the NovaChat 7• Marsha used the device with direct access for 6 monthsbefore alternative access methods were required• Marsha learnt to use the scanning displays with a microlightswitch, although this was very slow and tiring for her• A low technology headpointer allowed her to continue toaccess the keyboard directly, with slightly faster speedBack to case studies

Tara – Where is she now?• Tara trialed Big Mack communicators x 2, and a 4 CompartmentCommunicator with 3D symbol referents either next to (Big Mack) or onthe device (4 Compartment Communicator)• Tara’s GAS communication outcomes were disappointing (-2). Taragrabbed for the real objects but did not appear to make the connectionbetween the object and the target/voice message.• She was highly distractible and appeared overwhelmed and confused bythe objects/equipment• Tara was trialed using real objects only to request items. Tara showedmuch greater success with these.• Tara’s mother was actively included in the trial process to ensure herunderstanding of the communication goals.Next

Tara (contd)• Overall, it was agreed that technology might not be a priority at present –work on gesture, eye gaze and use of real objects to develop basicinteraction skills – requesting, refusing, turn taking etc, along with switchtoys to develop cause and effect.• Tara’s Mum and teacher aide (TA) were included in structured therapysessions to develop their facilitation skills. The TA followed through withrecommendations and Tara’s understanding of cause/effect andintentional communication improved significantly.• Informal gestures for “more”, “stop” and “my turn” were shaped intomore conventional Key Word signs• Big Mack’s were reintroduced with success, for Tara to make choicesbetween activities.• Technology options to be further investigated now that Tara hasdeveloped skillsBack to case studies

Oliver – where is he now?• Oliver initially trialled a Tobii S32 and Dynavox M3.• He showed very little interest in the static display device, but was highlyinterested in and motivated by the dynamic display.• His GAS outcomes with the M3 were excellent (+2) – both in terms ofcommunication output and motivation.• Page sets in M3 device will meet current and future needs• Oliver showed great care for the device – very protective• Family and team agreed that it would be valuable to try alternativedynamic display device to ensure best choice – trial of NovaChat 7• Oliver reluctant to trial something new. Pushed device away. Concernsabout behaviour• Design of M3 also considered to be more robust• Decision to apply for M3Next

Oliver (contd)• M3 delivered and introduced at home and school.• Oliver’s motivation to use the device with set ups used during the trial wasnot sustained• Oliver preferred exploring device, rather than using it to communicatewith purpose• SLP, school team and family required to “take stock” and carefully considervocabulary and choose items and situations that are highly motivating forOliver.• Mum quite disheartened by Oliver’s response, but feeling better afterteam meeting.• At his last review, Oliver’s use of the device is now focussed to makingsimple requests when prompted, with increased focus on modelling of thedevice• Informal behaviours continue to be his main form of communicationBack to case studies

Jo – where is he now?• Trials of range of accessing methods in conjunction with OT• Eye gaze was determined to be the most efficient access method for Jo.Headpointing too fatiguing on Vantage Lite• Jo attended an Assistive Technology appointment to see a range of SGDoptions both unity and other language / spelling based.• Accent 1200 trialed with NuEye and Eco 2 with EcoPoint due to Jo’s strongpreference to remain with a unity based system.• Jo perceived he was able to calibrate and use NuEye system moreefficiently than EcoPoint. Size of Eco 2 screen also non-preferred.• Jo encouraged by interest shown by peers during trials of Accent 1200.Pleased that peers engaged more• Decision to apply for funding for Accent 1200 with NuEye eye gazeaccessing equipment.Next

Jo (contd)• Mounting issues were investigated once device set up• Mounting device was challenging, and required expertise from CPLAssistive Technology services, particularly to ensure safety in PWC• Device proved to be excellent for communication and study at TAFE• Jo’s circle of friends did not grow significantly, but the quality offriendships improved with access to email etc• Jo was referred to a social worker (SW) to explore issues of transition,independence etc. SW not supported in his interactions with Jo (SLPservices unavailable), however, they muddled through together• Jo reported that sessions had been helpful and he was less anxious aboutthe future – in particular, feeling lonely and vulnerableBack to case studies

ReferencesReferences.pdfNext

Online Survey – FeedbackWe very much value your feedback to furthersupport the development of this resource.The following link takes you to an on-line survey andwe thank you in advance for taking the time to fillit out.www.surveymonkey.com/s/5MG992WNext

Contact Details• Debbie Burmester, Senior Speech Pathologist,Cerebral Palsy LeaguePh: (07) 3240 4055• Diane Clarke, Principal Clinical Advisor.Medical Aids Subsidy SchemePh: (07) 3136 3503Back to start