Team Approach article (InFocus magazine 2021)

A Team Effort: An application of communication partner training to support a young
woman, K, with significant communication and interaction needs.

by K’s family members, the support worker team (Jodie, Bron, Vicki, Jess), and Jane (SLP).

 

Summary

This news item summarises an intervention approach for a young adult with significant challenging behaviours and complex communication needs. Interventions were founded on a communication partner training approach and delivered solely by her family and support workers over a three year. The process and outcomes highlight how:
1. it is a mistake to consider someone in ‘a too hard basket’.
2. a multimodal communication program can be co-designed for best outcomes.
3. a communication partner training program can be delivered remotely and as telepractice.

I, Jane, have compiled this article with permission and input from all the team. We hope it will inspire readers and remind them of David Yoder’s words “Nobody is too anything…”

 

Introduction

In December 2017, an opportunity presented to provide an intervention to a young woman interstate. The young woman had extreme challenging behaviour and complex communication needs (CCN) arising from autism and compounded by movement disturbance and sensory-motor difference. The young woman who will be referred to as K, was seen once in 2017 face to face in her home for assessment purposes. It was obvious at the time, that it was not appropriate or safe to provide a speech pathology intervention face to face. Considerations at that time included a lack of local speech pathology services to provide direct or indirect support, periods of restrictive practices (seclusion, chemical, environmental, and physical), high levels of frustration and anxiety, a need to build trust and rapport safely. In discussion with her family, it was decided to try an indirect approach with an emphasis on knowledge and skill development for the people who knew and supported her in the family home.

 

Key assessment points

In her childhood, K had been exposed to classroom use of Key Word Singing (KWS) and a Go Talk communication device. There was no evidence that Augmentative and Alternative Communication (AAC) had been continued after her years in specialised education support. Aided communication, in particular high tech was not identified as viable due to the risks involved and K not allowing staff or family to use technologies including their phones and
computers. There was also no evidence of communication partner training for family or support staff. K’s speech and language featured perseverative words (particularly when anxious), single words with significant articulation errors, and an ability to answer questions often with ‘OK’ for the affirmative. Her mother reflects that:

‘In 2017 our life was a roller coaster ride. The ride was constant, it never ended, and we had no control over the ride… K did not have the skills to communicate her wants and needs verbally, she was very frustrated and communicated through unwanted behaviours. Nor did K have the ability to cope with the impacts of sensory integration disorder. At times K was very agitated and aggressive… K could escalate very quickly, sometimes attacking intensely with little or no warning. K was at times also extremely controlling. Not only of her physical environment, but also anyone within it e.g. doors and windows were not allowed to be open, no TV was allowed on in the house, family and support workers could not wear jumpers, glasses or shoes. At one stage family members were not allowed out of their rooms, and certain members had to eat outside’.

With an interest in communication partner training, I discussed with the family an alternative way of delivering a service to K. I envisaged that primarily a series of one day workshops might assist the team supporting K. I did not ever anticipate the positive outcomes that would occur for us all.

 

Designing a communication partner training model

Communication Partner Training (CPT) has been consistently identified in the literature as beneficial to both users of AAC and those with whom they interact In a meta-analysis of the outcomes of CPT, Kent-Walsh et al. (2015) determined that ‘the central finding of this review is that communication partner instruction has positive effects on communication performance of individuals using AAC’ (p.279). Also, in 2015, McNaughton and Light reported that
‘partner training is now widely recognized as a key component of effective interventions’ (p. 266). However, from the perspective of the person with CCN, communication partners play a pivotal role where ‘some partners were “wonderful” and others were “hell”’ (Trembarth et al., 2010, p. 84). Therefore, it was important to deliver training that was meaningful, to listen to the team, to collect written, photograph and audio-visual data and to design training that met their immediate needs. The following table summarises the CPT design between 2018 and 2020.

 

TRAINING CONTENT OUTCOMES
2018: 3 one day (6 hr) face to face workshops. Aim to develop understanding of difference and what AAC is about. Respond to team’s strengths.
  1. Introduction to AAC and collect data on K and knowledge/skills of team members.
  2. Introduction to KWS. How speech and language happen. Introduce Social Stories.
  3. Review and extend KWS and Social Stories. Introduce information on Autism, movement, and sensory disturbance.
  1. Team members had some knowledge of KWS. Develop this knowledge and skill.
  2. Introduce Makaton Project data recording sheets.
  3. Team able to identify the difference between Social and Information stories and use KWS at sentence level.
2019: 3 one day (6 hr) face to face
workshops. Respond to K’s interest in speaking and signing. Examine ways
aided communication can be introduced safely.
  1. Review Social Stores and introduce Zones of regulation, and Cued Articulation. Catch up for new team member.
  2. Introduction of literacy to support AAC and speech that is now being heard more.
  3. Introduction of light aided communication e.g. wipe boards and visual schedules
  1. Social Stories used to praise behaviour in functional activities. Team to speak as
    well as write Social Story style. Zones will not work as K has no colour concept. Cued articulation will be helpful.
  2. Workshops continue to be evaluated by team as ‘highly valuable and effective’. Team carry wipe board and use for
    choice, sequences, and mind mapping. Light choice displays for sensori-motor
    activities as well as daily living choices. Making AAC accessible.
All workshops include from trainer: quizzes, activities, role plays, lecture, slides, videos
All workshops include from team: data collection and homework share, team support
2020: Covid 19 and move to telepractice weekly from May and supplemented with self-paced and online courses in becoming a better communication partner. Training moves to indirect support to family e.g. writing and reviewing the Social Stories written by team members as K’s anxiety escalates. The 2019 work on Mindfulness shows new value. Photos used for Chat books and S. stories. The Connect Me Tool Kit is compiled. Review ways to maintain and keep extending team knowledge and skill. Team is consistent and diligent, supportive and confident. Team can KWS at sentence level with naturalistic conversational speech. Team can use light aided communication in a variety of contexts. K initiating spoken, signed and aided communication and uses language in conversational style; demonstrates ability to respond, ask questions, show humour, give feedback. Mean length of utterance 4.5 words.

 

Comments from the team.

When we started, we did feel a little overwhelmed, but we took it step-by-step. We started out slow and overtime K and her support staff have worked together to use AAC every day. When we introduced KWS into our everyday interactions with K we started off with single key words but now we can all use KWS sentences that relate to Kate and her wants and needs and interests. We used story books and KWS songs to practice our skills and we have all
encouraged and helped each other. Our success, and K’s has stemmed from keyword sign, modelling and being consistent. Kate now uses sign throughout her day and her sign vocabulary is getting larger. Currently, we use 150 signs in our natural speech with her and we have recorded that K uses a third of the number of signs we expose her to, and often with speech as well.

Social stories have been personally a hard concept to get our heads around but with practice and guidance we are improving not just writing them but using the language of the stories in our speech with K. Probably like most people, our first social stories were more information stories and were pitched to telling her what was going to happen. We can now see K listening and learning the language in the Social Story framework and we observe that
her anxiety lessens or lowers in a situation where a social story is used. We have even seen K initiate a conversation from the social story.

K’s conversation interactions have also improved with the assistance of Chat books. Not only are Chat Books great to help new people to interact with her but they have helped us to slow down our rate of speech, use less words in sentences, but still get across the same meaning. We are also now more aware of scaffolding the levels of conversation in particular not going straight from open questions to providing the answer but to use choices more.
AAC is far more than signing or using a communication device. Our training included sampling many different types of AAC with our trainer and working out as a team which one would work for her. All of us were willing to have a go and not let K be in anyone’s “to hard basket”. Having lots of strategies to draw from and to support each other with our never give up attitude has been great -what may not work one day may work another day. Strategies
that have been really important include modelling, active listening, scaffolding, using unaided language such as gesture and readable signs, slowing down, expanding on a word she may say or sign, presuming competence (least dangerous assumption). We often say we have planted the seed and let’s see how that seed grows.

The face to face workshop has its place, as do video connections for training. In either, we can still listen to each other given positive feedback, lots of encouragement and a safe place to make our mistakes, learn from each other and support K to be the best she can be.

Comments from K’s family.

The communication partner training approach has proven to be beneficial and enabled K to trust the team members and for team members to know her better. I did not expect that K would be able to sign – and now I am amazed. This has contributed to a reduction in anxiety, the frequency, duration, and intensity of outbursts; an ability to achieve goals and for K to communicate more clearly. K’s spoken language is clearer, her sentence length has increased, she is more fluent, the tone of her voice is more natural (less robotic), and she can also self-regulate
better. An example of this would be when K had recently had a major melt down and was de-escalating on her bed. I asked my son to read her one of the Journey to Calm, Social Stories that had been written for her. He did. Kate took a deep breath and calmed. We both thought and said, “well that worked!”. I did not think the gains we have made were achievable so my advice as a parent of a young adult with complex communication needs is…keep an open mind, enjoy the journey, and reap the rewards.

 

Where we are today:

In parallel to the training there has been an enormous amount of data collection. It has always been a challenge to use time for data collection wisely and to streamline as much as possible how data is collected. It is also important to remember that data on communication is only one aspect of the data collection that a support team have to take responsibility for – as an accountability measure and a requirement by funding bodies and individual allied health team members. Therefore, in a team training session we came up with a template similar to a Mind Map (as shown below) and we are trialling this as a data recording method that can be inclusive of the multidisciplinary team and shows interactions for the dynamic event that theyare.

As 2020 draws to a close this team is more confident to apply AAC and the strategies K needs. Most importantly, they now have the knowledge and skills needed to support new staff to K’s team, especially as she begins a transition to an independent style of living in the community. We all make mistakes, no matter what our role in a support team is. The biggest mistake we can make is underestimating the skills of others and out capacity to assist them.

 

2021 Update: 5 key points

1. Progress continues
2. Online support meetings continue and include reviews of the Becoming a Better
Communication Partner Package https://drjaneremingtongurney.podia.com/
3. Data collection continues
4. Some support staff now able to use their Communication Partner and AAC skills to
better support new staff.
5. List of 30 spoken sentences from K will be included in her annual progress report.

This article was first published in the InFocus Magazine for the Australian Group On Severe
Communication Impairment, December 2020. Issue 48. Page 28

Leave a Reply

3 × five =