Author: Maggie Sauer, CCC-SLP
APPROACH
communication training with caregivers
using switches for toys and other environmental control activities.
AGE AT INTERVENTION
9 years
ABOUT MICHAEL
Michael attended his neighborhood elementary school.
He enjoyed a close relationship with his family, listening to rock music and playing with his dog.
Michael had profound brain injury as a result of a near drowning accident at the age of two.
At his initial evaluation, his speech consisted of a variety of sounds. Michael's parents reported that he wanted to make his wants/needs known but was often frustrated by his inability to do this. He used multiple positioning aids and was dependent for transportation, meals and other daily care.
Michael's family requested an evaluation of his communication and recommendations to enhance his ability to more independently express himself. An interdisciplinary team participated in the evaluation with Michael's parents. The team members included an occupational therapist, physical therapist, physician, speech/language pathologist, and psychologist.
The evaluation took place at a clinical center outside his home. For that reason, the family provided a videotape of Michael in his home environment, which included daily activities, and the seating systems he used there. The team felt it was important to use informal observation in combination with formal evaluation to provide a better idea of Michael's abilities. The goals of the evaluation included:
1) Suggest ways of improving his communication abilities.
2) Decide if his seating systems enabled him to move as independently as possible while communicating and performing functions of daily living;
3) Decide which motor movements was best for controlling switch toys, environmental controls or communication displays;
4) Decide what he understood within his environment; and,
5) Decide how he could best express/indicate his understanding.
MICHAEL'S STRENGTHS
Since head and hand movement was easiest for him, activities using a nearby switch were most successful. The videotape provided by Michael's family demonstrated that he used similar skills in his home environment. However, it was evident that he also responded and anticipated certain routines in the home during mealtime, bath time, or bedtime.
His parents noticed differences in his vocalizations and offered him choices (e.g. hunger, pain, gaining attention, spending time with family members, favorite toys or activities). Michael understood the words representing these choices and made sounds as a means of requesting them. His family listed the objects or activities aloud and Michael would respond by becoming quiet when he heard or was given the desired item. Michael also used his eyes to request things in his environment. If he saw a toy or person he wanted, he would look at the toy or item and vocalize.
IDEAS TO IMPROVE MICHAEL'S COMMUNICATION
Michael used a range of communication skills. It was important for all the people in Michael's environment to recognize these communication attempts and encourage them in order to develop communication skills that would enable unfamiliar people to understand him.
When his parents came to the evaluation, they did not feel that he was communicating. However, upon discussion, they realized how much he actually did communicate even if speech was not the primary means of communication. Their present communication strategies with Michael could be used to build more opportunities for communication.
RECOMMENDATIONS
The following recommendations were made with Michael's family to help them understand Michael's communication and to help Michael become a better communicator:
? Provide consistency to Michael's communication
? Increase opportunities for Michael to make choices
? Utilize photographs in conjunction with verbal descriptions/cues
? Provide opportunities for Michael to control his own environment
? Provide opportunities to play by borrowing toys from a lending library
? Utilize other assistive technology resources in NC
1. An inventory was provided to his parents to help them record Michael's response to a variety of activities in the home. In this way, they could observe his communication behaviors as well as respond to them in a consistent manner. This was particularly important because there were a number of other people who helped them provide care to Michael. It was evident in the videotape from home that each person responded differently to his behavior and vocalizations. Caregivers, family and friends needed to recognize Michael's communication and respond in a consistent manner. Consistency would be important to help Michael understand how to communicate more effectively.
2. Michael would benefit from opportunities to make choices about things throughout the day. To begin with, things that were most important to him should be offered as choices. Initially, choices could be provided using two objects (e.g. toys, food choices). One item being some toy or activity he liked and the other a toy or activity he didn't. This could be done initially to help Michael understand that his choices make a difference in what he does. Additionally, because Michael presented difficulty with visual scanning, the occupational therapist provided strategies for optimal locations to present the objects during choice-making. A range of placement options was provided for use during communication and at other times throughout the day.
3. Michael's environment could be labeled with large simple color photographs of familiar items and people. For example, if Michael was going outside to spend time on his adapted swing, he would be shown the picture and a verbal prompt such as "Michael we're going outside to swing". At that time, the picture of his swing would be presented before going to the swing and again when he was placed in the swing. Introducing photographs in this way can assist him to a) anticipate the activity, b) begin to attach meaning to the photo, and 3) increase receptive vocabulary skills. Introducing photographs in this manner is effective because he is able to see, hear, and experience the activity. It is important that opportunities to develop this skill occur in his natural and familiar environment where the event and learning would be most meaningful. Michael's response to this type of activity would provide important information about his ability to use pictures for communication.
4. Michael had limited opportunities to control his own environment. Switches used in combination with switch-adapted toys and household appliances were suggested to enable him to more fully participate in his environment. His accuracy in activating switches was dependent on good positioning in his chair and other seating systems in his home. This was discussed with his family who were then shown how to place the switches next to Michael while he was in his seating systems. It was easy to see during these demonstrations how important positioning was to Michael's ability to reliably activate a switch with his hand or head.
5. Rather than recommending purchase of specific toys that he may or may not be interested in, the lending library at Generations/Tadpole was recommended as a way of trying different activities and toys. Generations/Tadpole makes the items available for three weeks free of charge. They are delivered by UPS directly to people's homes. His family could contact the library at 1-888-ATTRYIT or by email through http//:www.TADPOLE.org. Because Michael's funding for his medical and daily care needs was difficult to access quickly, this provided an immediate way for his family to access these resources. Another source for equipment loan is the Check-It-Out website. Assistive technology equipment that is available for loan statewide is posted on the site at http://www.check-it-out.org.
6. North Carolina also has an Assistive Technology Project with a resource center in Michael's community. It was recommended that Michael's family get in touch with their local resource center in order to see what is currently available to meet his needs as well as other resources related to funding etc. The North Carolina Assistive Technology Project's can be contacted by calling (919) 850-2787 or at their website http://www.mindspring.com/~ncatp/.
Michael's family was asked to return in three months for a follow-up visit for further suggestions and activities.
Evaluation is an ongoing process that requires the team to work together with the family as part of the team to determine what works?.and what doesn't. Although the word evaluation seems to imply a beginning and an end, we all grow, our interests vary, and our own skills change. Michael is no different. In order to keep pace with his change, an ongoing dialogue between all team members was critical to determine the "next steps". Michael was just beginning to let the world know he, too, wanted to "play".
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