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Article 4. What Master Clinicians Do and Think

I believe Carol Goossens was first to write about a case wherein traditional assessments came after, rather than preceded, AAC intervention.¹² A young girl from Vietnam with severe cerebral palsy did not speak or seem to understand language. Traditional assessments were not possible because of second language issues, her lack of speech and her lack of a reliable response mode. Was AAC intervention delayed until her functional status could be determined? Of course not!

The decision to intervene in AAC is not dependent on a person's cognitive, motor, speech, language, or sensory abilities. In fact, the very tools and techniques used in AAC can circumvent even the most severe impairment. The desired outcome of each AAC assessment, then, is to get started and make progress so the individual can communicate and thus realize his or her goals and aspirations. In the case of the young girl, an Etran was introduced. She was taught to eye point to symbols during play activities. Parallel switch training began for computer access. Over time, other things about her became obvious because she learned symbols quickly and used them appropriately. See Goossens' article for a complete description.

AAC professionals rarely begin an intervention knowing a fraction of what they'd like to know. Assessment is the vehicle used to develop a "working hypothesis" about where to start, and once the process is underway, what to do next. Since the assessment process can seem overwhelming, I asked master clinicians, what they really do during an AAC assessment and why. Table V (not included) summarizes their responses. The Table and related discussion are an effort to consolidate the vast amount of information shared by these professionals. However, this is only a beginning step along the path of future discussions, which should include other stakeholders, that will lead us to more valid and reliable approaches to assessment in AAC.

Major questions: The questions being asked by those interviewed are consistent with the philosophy and practices unique to AAC intervention as discussed earlier in this issue. For example, the importance of (1) clarifying and meeting the expectations of various stakeholders and assessing (2) the individual’s current ways of communicating (3) current intervention objectives, (4) preferences (5) communication opportunities, (6) existing barriers, (7) schedule, (8) language capabilities/limitations, (9) personal strengths and challenges, (10) where to begin and (11) the person’s support system.

Tools/strategies: Assessment methods used most often are interviews, observations (in natural settings whenever possible), and a review of past records. Building consensus is also important.

All concur. We need valid, reliable tools to help answer each major question. In the meantime, refer to references cited in Table V (not included) for examples of available tools.

Desired Outcomes: AAC intervention means managing a complex organizational process. Our assessments are an effort to capture that process. The process is continuous, not discrete–assessment begins, but never ends. Diagnostic therapy and diagnostic teaching were thought by many to be better descriptions of what actually happens in AAC where no real dichotomy exists between assessment and intervention.

Again, all concurred. The desired outcome of an AAC assessment is a "working hypothesis" based on an understanding of the people and situations involved, a consensus, and a plan. Even the most experienced team can not know if their recommendations will meet expectations, enhance opportunities, or overcome barriers. Likewise, only time will tell whether AAC tools, techniques and strategies will improve communication skills in ways that are meaningful to the consumer.

The National Joint Committee for the Communicative Needs of Persons with Severe Disabilities, says "assessment encompasses the following features:¹⁶

• Identifies current modes the individual uses.
• Includes measurement of sensory sensitivity by appropriate professionals.
• Identifies social functions of communication behaviors.
• Includes measure of a full range of performance across various environments.
• Is conducted in natural environments and a) identifies partners, b) measures opportunities across contexts, c) determines responses to communicative acts, d) identifies forms and functions needed in various environments, e) identifies persons who are most responsive across environments and f) looks for spontaneity of communication.
• Reflects an interdisciplinary model inclusive of consumers and their supporters.
• Encourages team members to share a common perspective on communicative behavior including an understanding that communication behaviors are social.

Master clinicians in AAC address these indicators–and more!

The assessment process in AAC is changing dramatically. For example, I used to work in a rehabilitation center (with a hospital, school, outpatient departments, and so on.) We did interdisciplinary assessments, many with an AAC focus. During these assessments, team members read previously written reports, interviewed caregivers, conducted speech, language, and communication testing, designed communication displays, solved positioning and access problems, recommended communication devices, addressed language concerns, made educational recommendations and so on. At the end of the admission or series of outpatient visits, a physician and social worker met with the family. Later (often much later) copies of our long, detailed reports were sent to the home-based team. Follow-up was minimal because we were swamped. Too often, not much changed.

Today, I go to a person's home, school, work-site, or community program. I talk to the individual and his/her family and friends about what they want to accomplish. I observe. Together we form hypotheses about which strategies, forms of representation, access techniques and opportunities for participation might help in situations throughout the day. I work with those already involved to generate an initial set of possible solutions. The team, which I am now on, develops an action plan (i.e., who is going to do what, by when, and how are we going to know that it is done/successful, or not?) We reach consensus. Little by little, step-by-step, changes are made. For me, it was a relief to learn that what I currently do, others are also doing. Looking deeper and more intently at assessment in AAC, I now think our approaches to assessment, even though they certainly lack uniformity, have real merit. I even think other professions could benefit from what we've learned. Our challenge now is to move forward by introducing scientific rigor into our evolving assessment practices and procedures.

This article appears in ACN Volume 7, # 1.

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