Month: May 2014

AAC Implementation in Mainstream Environments

It is estimated that there are nearly 165,000 students receiving special education services in the state of Massachusetts (Massachusetts Department of Elementary and Secondary Education, 2012), with approximately 9,854 being essentially nonverbal, and in need of some form of augmentative and alternative communication (AAC; Hall, 2013). Many of these individuals are supported in mainstream and inclusive educational settings. However, there are “many obstacles that can hinder a successful inclusion experience…[and] attitudinal barriers can be some of the most challenging and are often rooted in a general education teacher’s lack of confidence in his/her instructional skills when presented with students who have disabilities” (Kramlick, 2012, p. 106).

For students with complex communication needs requiring AAC, it is essential that he has access to his device throughout his school day. In addition it is critical that the student is encouraged to, and supported in his use of his device for a range of academically related, as well as social activities. Successful inclusion of an individual using AAC within a general education environment is contingent upon consistent collaboration among multiple team members (Kent-Walsh, 2003; Kramlich, 2012); and although it may be overwhelming to think of how to adapt the general education curriculum to support individuals using AAC, there are a number strategies that can be implemented.

a student uses his AAC device hooked up to a standard laptop
Figure 1: Third grade general education student uses his AAC device hooked up to a standard laptop to complete the MCAS

AAC implementation is a team effort. General education teachers should be supported by related service personnel from multiple disciplines depending on the nature of the student’s needs. Each team member’s goals (although specific to their specialty) should support and reinforce what is being done in class. For example, the AAC consultant can help ensure that necessary vocabulary is programmed into the AAC system, the student can locate the vocabulary, or knows how to use word prediction to type the relevant words. The speech pathologist can support learning new vocabulary, or embedding target vocabulary in complete sentences. The occupational therapist can work on writing or typing target words, or cutting out pictures of specific vocabulary. The physical therapist could work on having the student reach, range or ambulate to place pictures of target words in different locations, simultaneously supporting generalization of vocabulary learning while addressing gross motor goals.

a student using his AAC system
Figure 2: The same third grade student participates in a group reading activity in his general education classroom using his AAC system

In addition to this shared, collaborative teaming, there are simple strategies that can be used within the classroom. For starters, make sure all team members (including a student’s 1:1 support) are trained in the student’s device and that they receive regular consultation from an AAC specialist or other professional well versed in the student’s device. Offer a class training or discussion about the student’s device to help demystify it, and to show classmates that AAC is just another form of communication and how impressive it is that the student can use an AAC system as well as he does. Let the student using AAC lead a discussion, read a page of a book, or tell peers what is next on the schedule. Using AAC takes time so slow down the pace of a morning meeting or group activity to let the student comment on the weather, tell a joke, share an answer, label a color, or tell a friend it is her turn. Connect the student’s device to a computer so he can type letters, words, and phrases in a word processing document. Have the student use his device to do math problems or count. Most devices have phonics pages, so help the student explore different letter sounds, rhymes, or word endings. Most importantly, always have the AAC system available and use it with the student. The more the device is accepted and modeled as an effective communication tool, the more the student will use it. It is our attitude and willingness to involve AAC that will help ensure successful AAC implementation within general education environments.

References:

Hall, N. (2013). An Investigation of the Efficacy of Direct and Indirect AAC Service Provision via Telepractice. Open Access Dissertations. Paper 743.

Kent-Walsh, J. E. & Light, J. (2003). General education teachers’ experiences with inclusion of students who use augmentative and alternative communication. Augmentative and Alternative Communication, 19(2), 104-124).

Kramlich, C. (2012).Perspectives from general education teachers, students and their parents: Including students with robust communication devices in general education classrooms. Perspectives on Augmentative and Alternative Communication, 21, 105-114.

Massachusetts Department of Elementary and Secondary Education. (2012). Selected Populations (2011-12).

Accessible Housing

Mallory with her boyfriend
Mallory and boyfriend Owen enjoying the New England coast after their move to Boston

When I got accepted to the Boston University School of Public Health in the spring of 2012, I was excited and thrilled, but underneath those emotions was a layer of dread and anxiety.  My acceptance meant that inevitably I would have to move from my home in rural Maine, to the big city. This of course was my intent when I applied to the graduate program at BUSPH, but the fact that the transition would now be a reality was nothing short of daunting.

I began telling people about the upcoming move for both my boyfriend and I, who use mobility devices to get around independently and would require fully accessible housing, and received varying reactions. Many people shared the same initial thought of, “What are you, crazy?” and we were told horror stories of the lack of accessibility within the city. I had spent months researching academic programs, and where I wanted to live, and although I had researched cities based on accessibility, but I refused to let my disability and physical challenges dictate the direction that my life would take.

We began the housing search feeling optimistic. Being from small, rural areas, we had what we thought was a reasonable budget and we had lots of connections in the disability community, both in the state of Massachusetts and nationally. What we found however, was that those things only got us so far. The university was supportive, but they had limited options for graduate students, and none that would be sufficient for two people who required accessibility.

In our early phases of searching, we started by looking specifically for just accessible apartments. We spent hours scouring Craig’s List only to find hundreds of old, cramped low budget apartments with flights of stairs for an entrance. There were many within our budget, and we discussed options of how we could “make it work,” through various accommodations or just being creative.

I called and emailed every listing that looked like something that could work for us. Nobody called me back, or responded to my inquiries.  With our modest budget and request for a fully accessible unit, we were not a realtor’s dream. One broker had a conversation with me about a unit she was sure would be “perfect”  but the conversation ended abruptly with a last interaction of her sending me a text message of just a smiley face emoticon.

Another woman called me back and we were able to arrange for a friend to do a video tour of the potential units she had in mind for us. Even from the short videos we could tell the apartments were not accessible, and the agent had no experience with any sort of disability.  We knew it was a red flag when her first question to me in our conversation discussing wheelchair accessibility was, “Is one or two steps OK?”

Finally, I took my blinders off of just wanting so desperately to move to the city and came to a conclusion that this was unacceptable. We should not be forced to accept something that wouldn’t truly work for us when other people without disabilities had thousands of apartments to choose from. We were looking to make a move that would change our lives.  We were both new at life in the city; we were going to be away from our immediate families, and taking on a lot of things for the first time. Wherever we decided to live, was where we were going to be for the good, the bad, and the very ugly.  At the end of the day we did not want to get into our apartment and have to exert the last bit of our physical and emotional energy to do something simple like use the bathroom. This was going to be our HOME. I understood that going to grad school would mean that I would have to make sacrifices, but I was not willing to sacrifice my inclusion in society for the sake of finding housing.

It was at that point that I decided to reach out to our friends in the disability community.  I contacted the regional Center for Independent Living and explained our situation, of how we were hoping to live independently in the city of Boston, and our tight timeline of needing to move in time for me to start classes at the end of the summer. The woman I spoke with was kind, but her response seemed automated as she began explaining the process for applying for subsidized housing. I kindly explained to her that I was not looking for that kind of support, simply buildings that were accessible.  She seemed surprised at this request and was silent for a moment.  It seemed odd to me, that in asking for LESS support, it could actually be more difficult of a request.

She referred us to a registry that listed all the accessible properties in Massachusetts and that could be searched based on various criteria such as location, budget, or specific accessibility features. However, in using this search engine, we only found buildings that were specifically for senior citizens, individuals that were of low- income, or were located a significant distance from the city, or a combination of all of those things. The more we narrowed our search, the fewer listings that resulted, and we started to realize that what we were looking for simply did not exist.

Just when I was actually considering deferring my educational offer, in a last attempt, I reached out to a particular property that looked promising.  It was far beyond our original budget and considered a “luxury housing development,” but it was fully accessible, safe, in the ideal area, and had amenities that would actually make our lives easier instead of harder. Within days, the apartment was ours.  It was a 500 square foot studio, so we knew space would be a challenge, but we saw no other options.

We have been living in Boston now for almost two years, and I have become even more passionate about the existing housing challenge. While many people living with disabilities are aware of the struggles to find accessible, equal opportunity housing in the city, I have learned that it is not necessarily common knowledge to those without disabilities. All students struggle to find housing in the city as more and more people move to Boston each year, but when I told my peers that we were given the option to live in a nursing home so I could attend school, they assumed I was joking.

People assume that all buildings have ramps and elevators, and bathrooms that can fit a wheelchair.  Until they start looking at things through a different lens, they just believe the city works for everybody.  The truth is that the housing options for people with disabilities are limited and segregated.

While the models that are available may work for many people, they should not be the only options. Housing is ultimately the foundation for all people to live healthy fulfilling lives and for people with disabilities, this component can be even more crucial. If people are forced to live in unsafe conditions or away from their peers just because they require accessibility, they will be even less likely to be able to achieve success in employment, education or other endeavors that would help them to become equal members of society.

With the thriving disability community in Boston, and the current political efforts to increase housing in the city, I do believe there is progress being made, but until we have everybody on board, and understand the level of this problem, there is still a long way to go!

When Behavior is a Means to Communicate Pain in a Nonverbal Individual with Autism

unhappy child on floor with mom comforting
Behavior as a mean of communication for nonverbal individuals with ASD

As a parent of a nonverbal child with autism it has been critical that members of my son’s medical team understand and appreciate the connection between his physical pain and his uncharacteristic behavior. Early on in my journey to secure appropriate medical care for my son, I was given a critical piece of advice from our pediatrician. He once told me “whenever there is a dramatic change in my son’s behavior that could not be readily explained by some known cause, to pick up the phone and bring him in to be seen.” I did not realize at the time how rare and how invaluable this piece of medical advice would be for our family. In fact, I can recall an occasion when my son started to randomly bite his hand. In an effort to stop the biting, the educators working with my son immediately began formulating a behavior plan to address this self-injurious behavior. But I thought, what if there’s more to it. I remember calling my pediatrician about the biting and bringing my son in to see him. As it turned out, my son had a raging sinus infection. Once the infection was treated, the biting behavior vanished.

To an inexperienced physician, especially in an emergency department (ED), assumptions on how to treat an initial presentation are often made based on an assessment map for a typical child. During a recent trip to the ED with my son, the physician on duty made a determination that my son’s pain level was low based on his behavior. He was not crying in pain and was not showing any other signs. My son was simply curled up on a stretcher, lethargic and weak. The imaging studies suggested that he had a small bowel obstruction and a CT scan was needed to confirm this diagnosis. The ED physician stated that “with children with challenges like your son, we do not think a CT scan would be feasible.” All I could think of was, if a CT scan was the standard of care for children presenting with abdominal pain and persistent vomiting, then my son would have a CT. A CT scan was eventually done and did confirm his diagnosis.

I see it as critical that ED medical staff get a complete picture of a child’s profile before jumping to assumptions about the level of pain or the degree to which a child with autism may cooperate on an exam. We as parents are key members of the treatment team that must educate providers that each child on the autism spectrum is unique. We have to work together to make sure that assumptions aren’t made based on previous experiences with other individuals on the spectrum. My son is so fortunate that his medical team is composed of exceptional professionals who understand that a child with autism is a child first and that behavior often serves as a way to communicate. Other medical professionals need to learn how to translate uncharacteristic behaviors. Understanding that each child with autism is unique, and that medical comorbidities exist. Each and every child needs to be comprehensively evaluated in an effort to provide the highest quality of medical care for individuals on the autism spectrum. For more information regarding medical comorbidities and autism see: https://nationalautismassociation.org/pdf/MedicalComorbiditiesinASD2013.pdf