Ever been stumped with introducing a client to AAC? Today’s podcast is the first in a three part series on AAC. Join us as we discuss early steps to promote effective AAC use with clients and families. 

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Episode 16: Choose Your Hard

Simple Tools with Denise: Picnic Fun!

Free Resource Library  <- Contains the Mr. Potato Head pictures mentioned.

Music: Simple Gifts performed by Ted Yoder, used with permission

Transcript

Denise: Hey there, fellow SLPs, today’s podcast belongs to a category I’m calling “So, You’re a Generalist.” If you’re a generalist like me, then you treat a wide variety of communication disorders and maybe you’ve had clients you wished you could send to a specialist. Areas like AAC and stuttering can be so intimidating.

But the more experience I have, the more I’ve come to realize that as generalists, we have the power and opportunity to see connections and patterns that underlie all communication disorders. Seeing these patterns helps us chart a clear path with complex disorders. We need this ability because those clients are going to cross our paths, specialist or no specialist.

Dan: Welcome to The Mindful SLP, the show that explores simple but powerful therapy techniques for optimal outcomes. I’m Dan, here with co-host Denise. And today we’re going to be talking about augmentative and alternative communication. Also known as AAC. Now, Denise, you’re a generalist, you said that many times. So what do you know about AAC? What did you want to share about AAC?

Denise: Well, not being an AAC expert, I’ve come a long way because I’ve been able to see patterns of cognition and behavior that can hold back any person who’s learning to communicate whether or not they’re using AAC. I want to share these patterns and what to do about them.

The problem I see, and I see it a lot, and I do mean a lot, is that families are more likely to get discouraged with AAC use when these issues with cognition and behavior are not resolved. They just don’t see it working for them or working for their child. Honestly, I’ve had very few clients who were effective AAC users when they started working with me, and most families had either given up on it or if they hadn’t the child wasn’t communicating effectively with AAC. For example, just choosing picture symbols, randomly without any real discrimination between the symbols. Um, that can give you an idea of how big the problem is with teaching someone to use AAC.

Dan: I remember last fall you saying, after talking to some clients that you needed to do a podcast on AAC and that’s what triggered this podcast. So tell me what triggered this.

Denise: Well, last fall, I had two separate conversations with two mothers of nonverbal children about AAC. Um, these conversations happened within a week or two of each other. Um, it was disconcerting. It was a little bit freaky in a way, because they both said exactly the same thing to me to explain why they had kind of given up on AAC or why they hadn’t fully embraced it.

Dan: What did they say?

Denise: I just know what they need.

Dan: What bothered you about that?

Denise: Well that really concerned me because you can’t really know what someone needs beyond the basics if their communication is as limited as it was with these children. You can know whether they’re hungry or sleepy or tired or frustrated and parents of non-verbal children really do get clued into that. But to just know the basics. I mean, that’s not enough for human development because we have so many more things we want to say that we need to say. Communication is a human need. It’s not enough for someone to just be guessing what you need. And I don’t believe these families gave up because they’re not devoted to their child’s wellbeing. It’s because they didn’t see their child being effective with it. They didn’t see progress with AAC.

Dan: This kind of goes back to the book that we talked about, Ghost Boy, at the end of the year. He also had things that he wanted to communicate, but everybody just did everything for him because he couldn’t commute to them.

Denise: Yes, and so frustrating to him. He had all of these words inside of him. In fact, we kind of talked in that podcast about how he was so discouraged when he thought he was only going to have 200 words, and then he ended up getting a different AAC device and where his vocabulary could be unlimited. Well, let’s dive into it. So the next few podcasts are to share their practices that have made me a better therapist overall, and that have carried over to AAC in particular ways. While not be an expert. I’ve seen clients who use AAC really progressed when I keep these things in mind.

Dan: Give us a little outline of how we’re going to talk about AAC.

Denise: Well, I’m actually going to do three podcasts on AAC. I named these podcasts Ready, Set, Go With AAC because I’ve organized the communication patterns I see in early AAC users into three stages, the get ready stage, the get set stage, and the go stage.

You won’t find these in any textbook, but it works really well for me when I’m setting my objectives for AAC clients. Today, we’re talking about the ready stage as we go through these podcasts on AAC. It’s really important to emphasize that no matter what stage the client is in, the family, the SLP, you need to be using some kind of AAC system with the child, even if it’s low tech laminated pictures, right? AAC users need to be exposed to tons of language, even when they aren’t using it expressively. Their language is picture symbols. So what I’m talking about does not replace using AAC, it’s a supplement. What I’m talking about are foundational skills to all communicators need and that are often missing in AAC clients. And what you’re going to be doing is doing this activity is along with AAC input.

Dan: All right. So today let’s get ready. What does that look like?

Denise: So I’ve heard some people say, well, the therapist or someone told me that my child isn’t ready for AAC yet. That’s not how we want to think about it because you’re always going to be inputting.

You’ll be using picture symbols. You’ll be touching them even if the child is not really skilled at that, it doesn’t know what each picture means. What I mean by get ready is maybe they lack interactive play skills and eye contact, or maybe they lack the ability to persist in something that’s challenging You know, that’s probably not news to any SLPs out there, but there’s another area I always check that maybe you haven’t considered before, and that’s the ability to choose. That’s what I want to spend the rest of this time talking about today. I’ve had so many non-verbal clients, AAC users or not, who came to me without the ability to choose.

Dan: How do you tell if someone doesn’t have the ability to choose?

Denise: Well, maybe I show them multiple pictures of activities to choose from, and they point to more than one at a time. I mean, sometimes they’ll honestly use their index finger and their pinky finger. So they can point to two pitchers at a time or their point to all the pitchers in a row.

And they’re not really choosing what they want to do, to try and choose them all. One of my clients has a device that he’s just now learning to use. Um, and he used to use, like I said, his index and his pinky finger to make two choices simultaneously on his device. So he choose ball and bubbles. We can only play with one thing at a time, right. So he didn’t really understand about choosing, um, he’s gotten much better at that now, and as we’ve worked on choosing, or sometimes they might fall apart emotionally, when they’re being asked to make a choice, I had this client once who loved to color. And so I asked her to point to a color board to choose which marker she wanted, and initially that caused her to just fall apart. If she couldn’t just grab the marker and go, but had to stop and deliberately choose a color, it was really stressful for her emotionally and that’s something we had to work on. Or they may just disengage emotionally when asked to make a choice.

Dan: So you have to really sit back and watch how they’re making their choices or not, and really clue into that. How do you then teach it as a skill?

Denise: Here’s the one activity I do with a puzzle. So I’ll have two containers, like I have a bag and a box and I take the puzzle pieces while the client is watching me. I put half of the pieces in a bag and half of the pieces in a box and close them up.

Okay. And then I asked them to choose where they want to look for the puzzle piece. And oftentimes they will touch both. They’ll touch the bag and the box at the same time. So I have to encourage them, I’ll pull them back a little bit and hold one forward and see if they’ll touch one deliberately and I’ll do that until they get used to choosing.

So this is really interesting. I looked at the data. But I have been doing this with a client just recently. So the first time I did this, he didn’t seem interested in the puzzle. Although I knew he loved puzzles, so that’s kind of a disengaging emotionally. So he needed some physical prompting to even move his hand towards the bag or the box and what you do, what I’ve been taught to do is you sort of tap them on the elbow and that moves their arm forward to make a choice, but you are not taking their hand and putting it on a particular container. So it gives them more agency. It just sort of gets the motion started but without the choosing. Yeah. So you kind of help them get that motion going. But the interesting thing was when we finished that puzzle, even though he needed a lot of prompting that first time he was so excited, he was delighted. So he really did enjoy the activity.

And the second time he did it, he was 77% independent at choosing. But what he did was interesting. He chose all the puzzle pieces from the box first, and then he chose all the puzzle pieces from the bag. The third time I did it, he was 100% at independently choosing meaning he on his own, moved his hand to choose the bag or the box, but he switched back and forth every single time.

So he chose from the box, chose from the bag, chose from the box, chose from the bag, until all the puzzle pieces were gone, which shows a kind of a mental tracking, right. And I thought, oh wow. I didn’t even expect that.

Dan: So he was able to make that shift. That’s cool.

Denise: And so you segue this into choosing pictures, understanding that choosing pictures represents choosing an activity. Oh, and by the way, I used picture symbols while we were doing this. I mean, I have the bag in the box and for me and the puzzle, but the AAC devices they’re to the side and we use words like, like put in or I do or you do. So, again, you’re doing that input as you do these activities.

Dan: So there you’re laying the groundwork by showing them how that works and pulling it in as part of the language.

Denise: Just like when we are doing activity with a child, when we talk all the time, um, this is their language. So using those pictures is like talking to them. So like, understand how that works. That makes sense. And I did this activity again with a shape sorter. So I put half the shapes in the box, half the shapes in the bag. I mean, you can, there’s all sorts of things, any ex, any toy that has pieces, you know, that you can build and put something you can do that.

Um, potato heads are great for this and they improve, you can make it more complex. Like, what I do is I have pictures that represent each potato head piece and I’ll put, um, just two pictures on a Velcro strip. I have actually used a paint stir stick, so it’s really long and I’ll put one picture of one and one picture of the other end. They cannot, with one hand, hit both of them. And I can’t spread your finger, use your index finger and your pinky and touch both, kind of forces the choosing, to choose a potato head piece. Um, I mean, you definitely could put the pieces in a box or a bag if that’s where they’re at or two different containers, but I moved them to using the pictures to represent the pieces and it helps them with deliberate choosing.

By the way in our free resource library, we’re going to have that potato head activity pictures for you to download. I use that for so many things.

Dan: And that’s available at SLP pro-advisor dot com slash free. Well, I have a quick question before we continue on. So is it important for this activity to have a non sequential aspect to it? If you’re building a pyramid. The pieces have to come in order, whereas a potato head, they can be random in any order. Is it important to stay away from a sequential where you’re choosing that of two different boxes?

Denise: I really do like getting away from the sequential order because so many of our clients who are using AAC have autism and they really want to do things. They have this OCD thing about doing things in a certain order, and they just might fall into that pattern where it’s not so much communication as I have to do this in this order. So I really do try and choose activities where you don’t have to do things in a certain order. That’s a really good question.

Dan: Tell me about another activity.

Denise: Another choosing activity that’s more complex that I love to do is building a menu for our play picnic, using pictures for the food and pictures for the animals that come to our play picnic. Now, I show how to do that in my simple tools video Picnic Fun. I have to tell you, one of my former clients went through all three stages of get ready, get set, go, using mostly the picnic activity because he loved it so much. He was so motivated by it. I mean, I try and switch things up, but he just always wanted to do it. And when he first came to me, he was one of those kids who couldn’t choose. He just zoomed. And by the way, we have the pictures for the picnic activity in our free resource library.

Dan: The video, the simple tools video is also available on our [email protected].

Denise: Yeah. So you can see how to do that whole activity…

Dan: In the activity section. Well, I can see where that ability to choose can affect so many more areas than just being able to choose between picture symbols. So, this can be really be a foundational principle for their entire life.

Denise: It is, like I said, foundational skills for all people who communicate. But I want to tell you a final story that just clues into what you just said. I was working with a non-verbal client and she had done PEX in the past, but wasn’t using AAC effectively. Her mother had kind of given up on it. Well, right away, we started working on choosing along with our other AAC goals and she struggled to choose, and it was hard sometimes to know what it was she was really choosing. But we kept at it. And honestly, I hadn’t thought we’d got very far when her mom told me this story. They were playing outside and this little girl loves, loves, loves to be outside. Well, it got late and her mom told her it was time to go inside. And her mom said now that she knows she can choose, she let me know.

She was not happy about going inside.

Dan: How dangerous,

Denise: I thought those words were so telling, now that she knows she can choose, because I had not thought of her as being passive. I mean, she was a pretty sparkly and spunky little girl. And I didn’t imagine that she had held back about something that she wasn’t pleased with. I think she just didn’t realize that she could choose, so she didn’t have the motivation to communicate about it.

Dan: That’s really what I’m hearing here. If you have a client who’s struggling with an AAC device, it may be that they don’t realize that connection between choosing and being able to communicate how they want to change their world. And I think that is pretty key because it’s really easy to grow up having the world happen to you. But once you discover that you can affect that, suddenly that communication becomes so important to you, you really gained that desire to communicate, which really suddenly then pulls in that AAC device is, this is now just more than a toy. This is my way to change the world.

Denise: You really hit the nail on the head. AAC users need almost more motivation to communicate because they have this extra step. They have to find the picture on the device or in their book. And as much as we want that AAC device to be glued to them, sometimes it’s not, sometimes it has to be turned on. There’s a little bit of delay there sometimes, so they need that extra motivation to make that communication work for them. So helping someone realize the power to choose helps them know they have the power to affect their world and that’s motivation.

Dan: Well, we want to thank everyone for listening to us today, as we’ve focused on getting ready to use an AAC device. What do you watch for, what do you look for? Because as you know, being The Mindful SLP, your job as the SLP, is to really step back and take a look and analyze everything. And that’s really what this get ready stage is all about. So next time we’re going to be talking about the get set stage, and we want you to come back. We’re going to talk some more about that.

Denise: It’s going to be fun. I think. Thanks for listening today. Be sure to check out our free resource library at SLP proadvisor.com/free. And hey, give us a five-star rating if you’ve enjoyed this podcast. And remember when you master the simple, the complex takes care of itself.

Dan: Thank you for listening to The Mindful SLP. We hope you found some simple tools that will have optimal outcomes in your practice. This podcast is sponsored by SLP pro-advisor. Visit SLP pro-advisor dot com for more tools, including Impossible R Made Possible, Denise’s highly effective course for treating those troublesome Rs.

Our link is in the show notes. If you enjoyed this podcast, please give us a five star rating and tell your fellow SLPs. And please let us know what you think. Join the conversation at SLP pro-advisor dot com .