Example of Treatment Plan

The communication matrix assessment was used to develop a treatment plan for Molly. The matrix is set out in such a way that makes it really transparent to see the next steps that child should be learning according to a developmental model. For Molly, this meant developing her intentional communication skills which were just beginning to emerge. She was able to use communicative behaviours to refuse something (e.g. turning head away or arching back). The plan was to now develop her ability to request. Motivating items were selected, for Molly these were a space blanket, a noisy bell toy and a fan blowing towards her face. These items were presented individually in a calm environment with minimal language used, then taken away accompanied by the word “gone”. Any movement or sound used by Molly was interpreted by the adult as a request for more and the item was re-presented with the accompanying word “more”. Over time, she began to turn her head towards where the stimulus had been indicating an awareness of the stimuli and the team took this response as a request for wanting it again. Molly is not yet reaching unless prompted physically and this is the current emphasis on intervention, when she moves her head in the direction of the stimulus an adult is physically prompting her to reach towards the item. This will need to be carried out many times and with many sensory based items for Molly to develop this into a conventional, intentional request for more.

Joan Bruno, Children’s Specialised Hospital (2003)

This assessment was developed in a Children’s hospital in America. The purpose was to provide an objective way of assessing a client’s optimal symbol size, ability to recognise grammatical categories that symbols represent, categorisation skills and ability to form sentences using a picture communication board. Test results then serve as a starting point for creating communication boards or page sets.

The TASP is comprised of different subtests, each focussing on a different skill.

• 
  Symbol size and number – allows determination of number and size of symbols that a child would be able to select from.
  
• 
  Grammatical encoding – demonstrates the child’s ability to recognise symbols of different word types such as verbs, adjectives and adverbs.
  
• 
  Categorisation – demonstrates the child’s ability to assign symbols to the appropriate category
  
• 
  Syntactic performance – determines the child’s ability to sequence pictures to form messages and simple sentences.
  

The TASP subtests are administered in order (as above), and continued until a ceiling is reached. The ceiling for each subtest is described in the manual. The scoring manuals are provided on disc and the assessment materials, e.g. symbols and category pictures are all provided. The symbol system used is the Picture Communication System (PCS).

The results can be interpreted and used as a direct guide to inform development of communication boards that capitalise on the child’s strength. They can also be used for target setting, which may include developing symbolic skills or working towards communicative effectiveness.

Practical Case Study

Alisha was three years old when she was assessed using the TASP. She has a genetic chromosomal impairment resulting in a severe motor speech disorder, and could only produce vocalisations and a few sounds. She was very communicative and used a mixture of signing (although this was difficult due to poor fine motor skills), and had a communication book with choice of symbols and photographs on each page. She used topic based communication boards to join in with nursery activities such as painting and singing. She was beginning to develop combining two symbols together (e.g. want drink, like bubbles) following lots of modelling by her communication partner and then lots of practice. The TASP was selected to consider Ailsha’s immediate and future potential using symbols and face to face assessment by her speech and language therapist and was carried out over two sessions to complete the profile.

This assessment had be carried out face to face with the child, rather than previous discussed assessments that involved an in depth knowledge of the child.

In the first section which was designed to consider appropriateness of symbol size and number, Alisha scored 100% with selection of 4, 8 and 16 symbols per page. With 32 symbols per page, 20% (1/5) symbols were correctly selected by Alisha.

The second section considered grammatical encoding. She identified

• 
  75% (6/8) of transparent verbs
  
• 
  80% (4/5) of people
  
• 
  13% (1/8) of adjectives
  

The third section assessed categorisation skills. Alisha scored:

• 
  100% in the transport category
  
• 
  0% in the food category
  
• 
  0% in the clothes category
  
• 
  100% in the animal category
  

The fourth and final section was attempted. This was the subtest for syntactic performance and involved Alisha pointing at two pictures in the correct order. The goal of this was to determine if Alisha could sequence a series of symbols to express a message. She scored 33% (2/6) with the subject-verb two word level task. She did not have any success with the three word level task.

The results summary sheet was completed and this enabled recommendations to be made based upon Alisha’s performance and assessment results rather than “guessing” the next steps. The assessment is not standardised but gives descriptive information and allows progress to be monitored and plotted in a more objective way. Using the assessment for Alisha allowed communication boards to be created which would develop her skills in extending her symbolic communication level.

Example of Treatment Plan

The results of all subsections were used to plan targets that would formulate Alisha’s speech and language therapy treatment plan.

Communication boards were to be created for a variety of topic based activities and should consist of 16 cells for the current time. The size of the symbols should be 1 ½ inches. Section two of the test had informed that Alisha had the potential to use symbols across a range of grammatical classes but this required extension. Aims were put in place to work on receptive knowledge and symbolic knowledge of verbs and prepositions. This was to be via 1:1 teaching by Alisha’s teaching assistant following guidance from the speech and language therapist. Alisha was able to categorise some basic to superordinate categories, and particularly categories that she had experience of, but not grammatical categories. This resulted in implementing targets to increase symbol and categorisation knowledge and semantic activities were suggested. Alisha also demonstrated the beginnings of being able to combine words, so this too was a focus of therapy, following a linguistic approach, (combining subject and verb) and a more functional approach, (combining want and activity).

This treatment plan had a heavy emphasis on developing linguistic skills which tends to be the prime focus of this assessment. Other skills which are essential in development of AAC are not as considered within this assessment framework. Professionals with knowledge of AAC would need to use this assessment to plan the linguistic aims at the level best suited to the child but to also use their knowledge to ensure there was a functional strand to intervention and that the child using the created boards had sufficient reasons and opportunities to communicate. Following a purely linguistic model is likely to result in difficulties with carryover and generalisation into their everyday environments.

This assessment and intervention planning tool is designed to help professionals work with family members and individuals with complex communication needs to determine the most appropriate technologies and communication strategies for individuals to communicate with their communication partners.

It features a DVD which illustrates five individuals with complex communication needs and their “social network” of family, friends, acquaintances, paid professionals and people in the community

Functional goal-setting and person-centred planning are the main features of this assessment. These are what guide the individual and his or her closest communication partners towards the most effective communication strategies and technologies not only to meet their daily communication needs, but also to enhance their participation.

The Social Networks Communication Inventory acknowledges and addresses the multimodal nature of communication and recognises that the social variables such as context and partner affect interaction patterns and modes of communication. This tool, therefore, helps to contextualise information drawn from other AAC assessments.

The goal of Social Networks is to improve the quality of the communication of the individual and also to improve their partners’ communication efforts. (Put another way, the goal is to improve interactions, not individuals.) It considers the current strengths and weaknesses of communicative interactions within an individual's current set of social networks, and uses this information as the basis for planning for future improvement and expansion of networks, topics, technologies and techniques.

With regards to AAC, Social Networks advises that people using high-tech devices tend to use their devices in only one or two circles of communication partners and with a very limited set of individuals. They also always include body-based means (gesture, gaze and vocalisation) among their most used communication modes across communication partners and circles. It is advised that even highly proficient people using AAC consistently use different forms of high and low tech communication device depending on context, topic, purpose and communication partner.

Using the Assessment

As part of the interview process, the client completes a communication diagram consisting of 5 categories (or “circles”) of communicators: life partner and close family, wider family and good friends, acquaintances, paid communication partners, and unfamiliar partners. They are supported to do this by professionals such as Speech and Language Therapists. The client identifies what modality (facial expressions, gestures, vocalisations, speech, use of symbols, alphabet boards, etc. they use and the frequency that they use that modality to communicate with people in each of their 5 circles. The client provides topics currently discussed with individuals in each circle and what topics the client wishes he or she could discuss, if given appropriate support.

Information from the interview schedule is transferred to a summary section. This summary identifies people within each of five circles of communication partners, modes used with people within each circle, those that are effective versus efficient, skill strengths and those needing work, representational strategies and techniques, and strategies that support expression and comprehension. 

Need to carry out assessment to be able to comment on it.

• 
  Physical access – a framework that describes physical movements that might be used to access an AAC device.
  

• 
  Visual processing – to ensure information is presented within the person’s visual field.
  
• 
  Visual acuity (symbols) – to identify the number and size of symbols that is most appropriate. Symbols vary in size from 4 per page up to 128 per page.
  
• 
  Visual acuity (upper and lower case letters) – to ensure the correct size of print which is to be used.
  
• 
  Identification of different types of pictures, such as symbols and photographs.
  

• 
  Categorisation – considers the person’s ability to assign symbols to the appropriate category.
  
• 
  Visual Scene Displays – to explore whether real life scenes aids the identification of target words or sentences.
  
• 
  Single word picture matching – to explore single word reading skills
  
• 
  Reading – with or without symbol support – to explore whether reading is helped or hindered by symbol support.
  
• 
  Sentence – picture matching – to explore sentence reading skills
  
• 
  Paragraph reading comprehension – to explore paragraph reading comprehension skills.
  
• 
  Spelling – to explore the level of spelling ability and the quality of any errors.
  
• 
  Alpha and numeric encoding – to investigate the ability to make use of letter or number coding as a possible time saving strategy for a keyboard user.
  
• 
  Iconic encoding – to explore the ability to make use of symbol combinations as a strategy to increase the number of messages on a communication overlay.
  

The Frenchay subtests are descriptive in nature and therefore can be administered according to the individual being assessed. The whole assessment does not have to be administered; the professional carrying out the assessment determines which sections are to be used dependent upon the intended outcome. The whole assessment can be administered and this may take place over more than one session. It would most often be too time consuming to administer the whole assessment in one session.

The results can be interpreted and used as a direct guide to inform development of communication boards and high tech AAC systems that capitalise on the person’s strength and will ensure that AAC options are most likely to be successful as systems can be created that best match the individual’s skills.

Practical Case Study

Emily is a fourteen year old girl who had a traumatic brain injury following an accident. She spent almost a year in hospital and was only able to communicate basic needs via hands movements in response to yes and no questions. She slowly began to regain some speech but it was highly unintelligible due to dysarthria (poor articulation, volume, respiration for speech and voice).Upon discharge from hospital, assessment showed that she was able to speak in single words and had retained much of her language comprehension. Her speech was mostly intelligible when using single words but if she attempted to put any more words together, the clarity of speech was lost and she remained difficult to understand. She also has severe difficulty with her expressive semantic system and significant word finding problems. She was keen to go back to her mainstream high school although required a slow phased approach due to physical difficulties, language difficulties, personality and behaviour changes and extreme fatigue.

The Frenchay Screening tool was used as a part of a whole battery of assessments to determine a baseline for her language skills which were likely to require some form of AAC. Only parts of the assessment were completed as it was physically tiring for Emily and her attention skills spans? were fairly short.

Physical access, identification of different types of pictures, categorisation, reading comprehension and spelling were targeted. It was felt that other sections were covered in the wider battery of assessment material. Considering reading was extremely beneficial and it was found that print was a useful medium to cue Emily into a word that she could not spontaneously recall.

Emily required a period of intensive speech and language therapy support, as part of a multi-disciplinary team consisting of physiotherapy, occupational therapy, clinical psychology, home tutoring and counselling services. Her main priority was learning to walk again and for her friends to know that she wanted to be treated the same as before her accident. Her priority for her communication was to be able to speak the same as before, and it was very difficult to encourage her to break this down into small manageable chunks.