Facilitating Literacy Skills in an Adult Who Uses AAC

1. Facilitating Literacy Skills in an Adult Who Uses AAC Melissa Ollie and Marie Swanson Minnesota State University, Moorhead Poster session at ASHA, Miami, 2006

2. Introduction • Literacy should be viewed as a right rather than a privilege for individuals who are unable to communicate vocally and require the assistance of various means of augmentative or alternative communication (AAC). (Erickson, Koppenhaver, & Yoder, 2002) • Individuals who use AAC are entitled to the right to… • service providers who are knowledgeable about the methods of literacy instruction • live and learn in environments in which all individuals are viewed as literacy learners • make life choices that are made available through reading and writing (Yoder, Erickson, and Koppenhaver, 1997, as cited by Erickson, Koppenhaver, & Yoder, 2002)

3. Purpose • The purpose of this single subject case study was to determine the effectiveness of using literacy instructional strategies designed for child AAC users to develop literacy skills in an adult with cerebral palsy who uses AAC.

4. Rationale • Most children who use AAC are not literate even at the most basic levels, and more than 50% to as many as 90% either cannot read at all or read below what is expected for their age-level. (Koppenhaver and Yoder (1992a) • Literacy is frequently not incorporated into AAC assessments or interventions. • Professionals feel there is not time to include literacy instruction in AAC. • Clinical programs do not routinely incorporate literacy in AAC evaluations or treatment packages. (Koppenhaver, 2000)

5. Rationale continued… • Literacy skills are important for AAC users • provides access to language • enhances communication and self-expression • builds critical thinking skills • opens doors to educational and vocational opportunities • increases self-worth • encourages independence • provides access to the world beyond the individual’s immediate surroundings (Light & McNaughton, 1993)

6. Rationale continued… • The ability to read is a valuable tool for AAC users as they participate in home, work, school, and social settings. (Koppenhaver, Coleman, Kalman, & Yoder, 1991) • Literacy skills increase the flexibility of an AAC system as the individual is capable of using a combination of symbols and orthography. (Beukelman & Mirenda, 2005) • Literacy should be as much a part of AAC as communication strategies, skills, tools, processes, and products. (Koppenhaver, 2000)

7. Challenges in Literacy Instruction • Literacy learning difficulties are clearly documented for children with severe speech and physical impairments (SSPIs), especially those with cerebral palsy. • Individuals with cerebral palsy may face the following challenges when learning literacy skills: • physical, visual, and auditory perceptual limitations (Beukelman & Mirenda, 2005; Smith, 1992) • reading opportunities are restricted in terms of length, number, range, and quality (Koppenhaver & Yoder, 1993) • misconception that they are not capable of learning to read (Light & McNaughton, 1993)

8. Challenges in Literacy Instruction • A limited amount of research is currently available on literacy instructional strategies for adult AAC users. • Literacy instructional strategies for the adult AAC population can be derived from the larger body of literature available on literacy development in child AAC users as adults require many of the same features of literacy instruction as do children. (Smith, 2005) • Assessment and instruction requires adapted curriculum and methods. (DeCoste, 1997)

9. Subject Information • Female, age 54, with a medical diagnosis of spastic cerebral palsy. • No records available on formal education. • No formal cognitive assessment; however, demonstrates cognitive delay. • Hearing within normal limits; visual-perceptual involvement. • No previous communication assessment or intervention.

10. Subject Information • Initial evaluation, September, 2004, for AAC through the Regional Assistive Technology Center in the Speech and Language Clinic at Minnesota State University Moorhead (MSUM). • Speech was her primary means of communication, however, her speech was rated 98% unintelligible. • Severe physical involvement: no controlled movements of upper body, controlled movements of legs and feet. • Accesses communication technology and instructional materials with the big toe on her right foot.

11. Subject Information • Enrolled in therapy at the MSUM clinic. Therapy goals have focused on: • enhancing her communicative abilities through increasing spontaneous initiations and responses • increasing the complexity of the syntactic structure of her utterances • increasing the variety of communicative functions • In June, 2006, the subject received a DV4 (Dynavox). • Simultaneously received language intervention and literacy instruction.

12. Methods • The subject was seen a total of 34 times over the course of approximately three months (July 18th, 2006 through October 27th, 2006). Each session took place in her group home. • The subject’s caregivers were asked to read to her for at least fifteen minutes a day from whatever text she selected (e.g., newspaper). Assessment • Data was collected prior to beginning each step of literacy instruction (initial phoneme segmentation, sound blending, letter names, letter-sound correspondences, and single word decoding).

13. Methods Assessment continued… • The following guidelines were followed during informal assessment: • 20 seconds were allowed for a response once the subject was visibly attending to the task. • Items were only repeated twice. • Verbal reinforcement was provided based on completion of items rather than correctness of response. • Performance measure was based on percentage of accuracy (e.g., the number of correct responses divided by the total number of items presented).

14. Methods Instruction • Interventions used for this study followed an outline of procedures presented by Light, McNaughton, Jansen, Kristiansen, May, Miller, Weaver, & York in a seminar, Maximizing the Literacy Skills of Individuals Who Require AAC, at the American Speech-Language Hearing Association (ASHA) Convention, 2005. • The interventions included instruction in phonological awareness skills (e.g., initial phoneme segmentation and sound blending), letter-sound correspondences, decoding skills, shared reading, and independent reading. In addition to the procedures used by Light et al., the clinician included instruction in letter names.

15. Methods • The following modifications, adaptations, and expectations were in place during each phase of instruction: • Instructional materials were modified to include graphic symbols familiar to the subject. • Instructional materials were placed on a podium on the floor to accommodate her visual and physical limitations. • Instructional materials were adapted to allow nonverbal response. • Subject accessed the materials pointing with the big toe on her right foot. • Unlimited amount of time was given to respond. • Unlimited number of item repetitions were provided. • Feedback provided on completion of items and on correctness of response • Percentage of accuracy calculated on the number of correct responses divided by the total number of items presented in the task. • Criterion was 90% accuracy across three consecutive sessions • Progress was determined by comparing percentage of accuracy during instructional sessions to data collected prior to beginning instruction.

16. Results • Pre- and post-instruction data on initial phoneme segmentation, sound blending, and letter-sound correspondences were collected through informal procedures within a single session. Post-instruction data was collected two weeks after instruction was completed.

18. Results • Progress was determined by comparing percentage of accuracy during instructional sessions to pre-instructional data and data collected at the beginning of each phase. The subject’s progress for each phase is presented in the following graph:

20. Discussion/Implications • The results of the study up to this point support the appropriateness and effectiveness of literacy instruction with this adult subject. • Preliminary “analysis” of the results to this point suggests the following implications: Psycho-social • The contrast between the initial data point (pretest) and the first and subsequent interventions suggests the subject may have had some apprehension about the new task. The initial session was a testing format, and the task involved no cueing following the initial instructions and no reinforcement of correct response. • This subject is typically reticent to respond in new situations and to respond to new task demands. She is anxious about making mistakes and hesitates to respond. Therefore, the contrast in accuracy between the pretest and initial interventions may be explained in part by the considerable support provided during the intervention sessions.

21. Discussion/Implications Literacy • Although the subject had no previous formal education or specific literacy instruction, the rate at which she acquired these specific skills suggests these skills may have been present to some degree. • During the communication intervention prior to this study, the subject had demonstrated a few sight words that were assumed to be memorized. She did not demonstrate the skills targeted in the literacy instruction. • These preliminary findings support the idea that literacy assessment and instruction be provided to AAC users of all ages and abilities. • Further, these preliminary findings underscore the need for ongoing research in adult literacy instruction with AAC users.

22. References Beukelman, D.R. & Mirenda, P. (2005). Augmentative & alternative communication: Supporting children & adults with complex communication needs. Baltimore, MD: Paul H. Brooks Publishing Co., Inc. DeCoste, D.C. (1997). The role of literacy in augmentative and alternative communication. In S.L. Glennen & D.C. DeCoste (Eds.), The handbook of augmentative and alternative communication (pp. 283-333). San Diego: Singular Publishing Group. Erickson, K.A., Koppenhaver, D.A., & Yoder, D.E. (2002). Waves of words: Augmented communicators read and write. Toronto, Ontario, Canada: ISAAC Press. Koppenhaver, D.A. (2000). Literacy in AAC: What should be written on the envelope we push? Augmentative and Alternative Communication, 16, 270-279. Koppenhaver, D.A., Coleman, P.P., Kalman, S.L, & Yoder, D.E. (1991). The implications of emergent literacy research for children with developmental disabilities. American Journal of Speech-Language Pathology, 1(1), 38-44. Koppenhaver, D., & Yoder, D. (1992). Literacy issues in persons with severe physical and speech impairments. In R. Gaylord-Ross (Ed.), Issues and research in special education (Vol. 2, pp. 156-201). New York, NY: Teachers College Press. Koppenhaver, D., & Yoder, D. (1993). Classroom literacy instruction for children with severe speech and physical impairments (SSPI): What is and what might be. Topics in Language Disorders, 13(2), 1-15. Light, J., & McNaughton, D. (1993). Literacy and augmentative and alternative communication (AAC): The expectations and priorities of parents and teachers. Topics in Language Disorders, 13(2), 33-46. Light, J.L., McNaughton, D., Jansen, J., Kristiansen, L., May, J., Miller, L., Weaver, C., & York, A. (2005, November). Maximizing the literacy skills of individuals who require AAC. Presented at the annual convention of the American Speech-Language Hearing Association (ASHA), San Diego, CA. Smith, M. (1992). Reading abilities of nonspeaking students: Two case studies. Augmentative and Alternative Communication, 8, 57-66. Smith, M. (2005). Literacy and augmentative and alternative communication. Boston, MA: Elsevier Inc.