OTS 53: AAC with The Fannypack Therapists
- Jayson Davies
- Jul 10, 2020
- 42 min read
Updated: Jun 24
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On this episode of the OT Schoolhouse Podcast, Jayson welcomes to the show the wonderful minds behind @TheFannyPackTherapist to talk about their specialty, Augmentative, and Alternative Communication. Annabeth Knight, OTD, OTR/L & Mara Jonet, MA, CCC-SLP have presented at conferences nationwide on the collaborative approach to evaluating and implementing AAC devices for children. In this podcast episode, we focus on that collaborative process and the role of the OT. We also talk about why AAC devices are sometimes underutilized and how to prevent users from abandoning their devices.
Links to Show References:
Follow Annabeth and Mara on Instagram: @TheFannyPackTherapist
Follow Annabeth and Mara on their brand new Fanny Pack Therapist website!
AOTA Position paper on Assistive Technology (Members Only)
ASHA Position Statement on Access to Communication Services and Supports
Be sure to subscribe to the OT Schoolhouse email list & get access to our free downloads of Gray-Space paper and the Occupational Profile for school-based OTs.
Have any questions or comments regarding our podcast? Email Jayson at Jayson@otschoolhouse.com
Well,
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Episode Transcript
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Jayson Davies
Why is it the fanny pack therapist?
Mara Jonet
So first of all, Annabeth and I are not only great coworkers, but we're also great friends who happen to be bonded in 90s nostalgia, and we are also very similar in our treatment approaches in that you don't need tons of toys, tons of games, a heavy bag to bring to every therapy session, and you should just ditch it and use yourself. So it was kind of like, well, you don't need anything more than a fanny pack to do a treatment session. So that's how our idea of the fanny pack therapist Instagram account started.
Jayson Davies
And there you have. It. A better introduction than I could ever give to Annabeth and Mara the fanny pack therapist. You can follow them on Instagram, and they are here today to talk about assistive technology and AAC. So let's dive into our Introduction music, which everyone loves, and then we'll come back and talk about some AAC, all right, see you in a second.
Amazing Narrator
Hello and welcome to the OT school house podcast, your source for school based occupational therapy tips, interviews and professional development. Now to get the conversation started, here is your host, Jayson Davies class is officially in session.
Jayson Davies
Hey there. Welcome to episode number 53, of the OT school house podcast. My name is Jayson Davies, and I am your host for today. As you just kind of heard, we are here to talk about fanny packs today. No, I'm just kidding. We're actually here to talk about AAC augmentative communication. And so we are going to get into that. We have two very special guests on today. They are collaborative team, an occupational therapist and an SLP, before the Introduction music, it was Mara jonet That you were hearing talking about how they came up with the name the fanny pack therapist. And with her, is actually an occupational therapist by the name of Annabeth Knight. And together, they are part of a collaborative AAC team that works in a private practice outpatient clinic for kids. And so they are here to talk about how they work together, along with other disciplines, to have this teamwork and just come together with a parent and everyone involved to put into place an AAC device or an AAC system that just works for that student. And so they're going to talk about the assessment process, and then the ongoing process that it takes to teach everyone involved how to use that system. They're really a great team. You can just hear it throughout this interview. They're really amazing, and I'm excited to have them on this is actually the first time we're having a speech and language pathologist on the show. So that's very cool. And yeah, so I'm excited to talk about fanny packs, and I hope you are too. We'll just talk a little bit about fanny packs. But, yeah, I don't want to. I don't have any other announcements to make today, so let's just dive into it. So please help me to welcome occupational therapist, Annabeth Knight and speech and language pathologist, Mara jonet, together, they are the providers behind the fanny pack. Therapist. Hello, Annabeth. Hello, Mara. How are you doing today? Let's go ahead and start with Annabeth. How are you today?
Annabeth Knight
Doing well today. We're excited to be here, and this is our first podcast,
Jayson Davies
so awesome. And how about you, Mara? Yeah,
Mara Jonet
hello, I'm doing great today. It's been a busy day, but super excited to have a kind of a long weekend. Yeah,
Jayson Davies
I hear that that's nice. So actually, Annabeth and I were just talking about this. Annabeth and Mara run the fanny pack therapist on Instagram, at the fanny pack therapist, and they are actually engaging in the oh so popular prank, or not prank, plank, 30 day plank, it's not a contest, but challenge. How's that going for you guys? It's going well. I was
Annabeth Knight
saying before it's nice because we're kind of tag teaming it, so one of us can't get to it one day, the other one can. And I
Mara Jonet
was just gonna say we're kind of at an advantage, since we're two people so we can, we can bounce off each other and have one or the other do it so we don't have to do all days. But other than that, it's really good, and we love the purpose of it, because who doesn't want to get a little bit stronger in their body?
Jayson Davies
There you go. Yeah. I was just telling annabev, I am not one to do planks, but I will ride a bike for like, hours and hours. So that's been my exercise lately. So well anyway, let's get into it. We are here to talk about some assistive technology at but even more so the AAC collaborative process, and so I'm excited to have you with us here to talk to talk about that today, but before we get started, I always like to give my guests the opportunity to go ahead and introduce themselves. So how about we start with Annabeth. Tell us about who you are as an occupational therapist and how you got into the fanny pack therapist realm. Yeah.
Annabeth Knight
So. So I am an Occupational Therapist. I've been working for almost nine years now, which is kind of hard to believe, and I started my career. My first job at a school was at a school for children with cerebral palsy in Philadelphia, and so I kind of got thrown into the world of assistive technology and AAC, almost every single kid on my caseload used some form of AAC, and so I was on that team right away, and just had a really tremendous opportunity to learn there and to work with so many OTs and SLPs and PTs and educators who had lots of experience in that area. And now I work in outpatient pediatrics with Mara, and we have just been sort of taking on a lot of those clients who we have at our company, who have at and AAC needs and building programs for them.
Jayson Davies
Gotcha. All right. So you started in the schools, but now you are in a pediatric outpatient clinic with Mara who is a speech therapist. Go ahead, Mara, how about you introduce yourself and what you've been up to? Yes.
Mara Jonet
So like you said, I am a speech and language pathologist, and I've been practicing for a little bit over five years. And in terms of, like, my passions, I'm really just passionate about complex communication needs and AC. So I was lucky enough to kind of cater my entire graduate school around placements with students who use AAC just to really learn that area. And I have only been working in an outpatient pediatric facility, but I love it because I get to wear many different hats. I get to wear a feeding therapist hat, and then I jump into an AC session, and then I jump into a language session. So it's never a dull moment. And I just love that I get to play for my job,
Jayson Davies
right? I do like that. We get to play, but at the same time, it's got to be difficult to work on feeding over teletherapy right now. How's that going?
Mara Jonet
It's been quite interesting, but, yeah, I actually was trained in telehealth in graduate school, so I'm not super new to the world, but it is new that we are all forced into this world, but feeding therapy actually works very well because you can use more of a parent coaching model and coaching the parents through, you know, the process of eating different foods and, you know, jumping up the hierarchies of that. So it's actually been going relatively well,
Jayson Davies
awesome. What about you? Annabeth, how is teletherapy going?
Annabeth Knight
It's been going pretty well. I mean, I feel like now we're we're in it, and I didn't have experience with it beforehand. I mean, Mara was really the most experienced therapist at our clinic when we made this transition. So she, she created the transition, facilitated that, which was such a huge undertaking, and we're thankful for that. But yeah, I think that I've really enjoyed the parent coaching model as well. I think for our kiddos who use AAC, we've used a ton of that parent coaching as well, and it's really cool to see the carryover happening, and to be able to see those barriers to implementation and address them in the moment, and not just be only in the clinic with a kiddo, maybe parents there or one of the caregivers, but it's just yeah. It's been nice to Nice to facilitate that in somebody's home, even if it's virtually
Jayson Davies
Yeah. Same thing goes with school based. I mean, we're so used to working with the teacher, and now it's less work with the teacher and more so with the parent, and so it's very interesting to say the least. So kind of a nice change. I like it, but with that, I am still looking forward to going back to the schools anyways. So let's start off. We're going to talk about at and AAC. Let's first start by defining at and AAC and how they might be a little similar or not, they're definitely not interchangeable, but how they work together, yeah, so
Annabeth Knight
at is assistive technology. So I like to think of that as an umbrella term, and it encompasses a lot of different things. So it does encompass AAC, but so assistive technology is really any product, equipment or system that's going to enhance learning or a client's ability to work or participate in activities of daily living at any level. And so there's a variety of levels of technology that we'll talk about as well within within assistive technology. So it can really include anything from like a sock aid to a power wheelchair to a high tech communication system to environmental controls. So there's a lot that goes along with it, and on the speech therapy side of it, AAC is a really, a really big piece of assistive technology. Yeah.
Mara Jonet
And AC stands for augmented and alternative communication, so that is housed under the umbrella of at but AAC refers to all forms of communication other than oral speech or oral spoken language, and so any form of communication that's used to express your thoughts or your needs or your wants, your ideas, protesting things like that, any way that you do that, other than spoken language, would be AAC. Some examples would include gestures or sign language. It would also include some devices, like an iPad, if someone uses that to talk, or a communication board or picture symbols, gotcha.
Jayson Davies
And I know this is kind of a loaded question, but before we go any further, I want to just hear it. I'm assuming Mara will probably answer this is why is AAC so important for our kiddos that are nonverbal?
Mara Jonet
Yeah, absolutely. So AAC is super important because communication itself is a basic right. Everybody has the right to communicate, and in order to accommodate that, some might need access to AC. So in order to provide everyone to access to communication, that's what AAC is for. There's the national joint committee for communication needs of persons with severe disabilities, and they published a fantastic list of the communication of the basic rights, or the basic rights that all individuals have access to for communication. So that includes the right to request, the right to refuse, the right to express feelings, the right to reject something, the right to ask questions and receive responses. And one more push is communication just really allows you to participate in your daily activities and your meaningful occupations. So that's why it's important.
Jayson Davies
Yeah. I mean, it'd be hard to live in this world if you didn't have some way to communicate. So fair enough, definitely. All right, I have heard some people argue that they don't necessarily understand ot in AAC. And so before we move on any further, why is ot such an important part of AAC, both in the evaluation process and beyond?
Annabeth Knight
Yeah, so I think Mara just touched on this in a nutshell, in order to access occupation and access participation in meaningful activities you need communication, and so that's where the OT lens is really, really important. And speech language pathologists also are looking at this. They're doing a needs assessment of all of the language that a client is going to need to use throughout their day. But as OT is because we are so trained in activity analysis and really analyzing what habits, rules and routines look like for these clients. I think it's really important for an OT to be part of that process, from evaluation all the way through implementation. And another piece of it really is that the OT is focus is to do an assessment of all of the multi sensory access needs a client might have, so especially for clients who have complex medical profiles and might be accessing a communication system in a way that we wouldn't consider typical, then the OT is going to be looking at all of the motor components of that, all of the different types of access they might be using how they're going to use their vision, how seating and positioning is impacting that, and really, really focusing on energy conservation as well. Because for lots of these kids, that's going to be huge, because they we want them to be communicating all the time. But it can be energy taxing. It can be a little
Jayson Davies
exhausting. Yeah, and I know one thing that we've had difficulties with in the school is the kids having access to their device at all times during the day. I mean, it's hard to carry your I mean, how? What is the best way to carry an iPad around the entire school campus? I think maybe we can save that for a little bit. We'll come back to that. But, yeah, let's start off with the different types of AAC devices or at devices. For that matter, I often hear from my speech therapist the terms high tech, low tech, and I believe no tech. But what do you guys
Annabeth Knight
use? Yeah, I love those three. And I would add in mid tech there as well. So on that spectrum, if we start with no tech that can be broken down into Aided Language or unaided or aided or unaided systems, so unaided no tech would be things like sign language or gestures, body language, anything where you're not using and. In any specific outside tools, and then aided would be something like a picture board or using a pen and pencil to write for communication, when you're using that thing that is external in order to help with communication, low tech then is going to refer to communication boards that have symbols or that have words, and that would be something that you might be pointing to to communicate, or you're accessing with low tech eye gaze, so you're looking at the symbol or the word that you want to communicate. Or you might be doing partner assisted scanning, where a communication partner is working with you, and they're reading through your choices, and you're indicating Yes, when you get to your choice that you want to communicate. And low
Mara Jonet
tech might also refer to something just as simple as a pen and pencil so you have access to written language,
Jayson Davies
okay, so just to write something down that that's easier, yeah, yep.
Mara Jonet
So anything without technology that aids in communication would be low tech, gotcha. Okay.
Annabeth Knight
And then mid tech starts to get into those, like, single or multiple message output devices. So some people might be familiar with, like a Big Mac or a step by step. So this is where you can pre program. You can record one or several voice messages that will speak upon activation, but they're not generative. So then those high tech devices are devices that are sort of like computerized communication systems, where they are generative. You're able to access a really robust language system, and you can create unique phrases. So those are the things that we'll refer to as speech generating devices, or like a device or a talker that a kid has is typically what that high tech is,
Jayson Davies
gotcha and All right, so I hear you saying all these different types of things that we could potentially give to a child, student, parent, any person who needs some help with with communicating, but when it comes to teaching someone how to use assistive technology or an AAC device. Is there a model to follow? Or where does one start when it comes to teaching someone to use AAC? So
Mara Jonet
the most established model is thinking about it as a different language and teaching a different language. So when you think of AAC, it is another language, and children have to learn that other language, similar to how children learn spoken language. So if you think of spoken language, babies hear their parents talk, and then they'll start playing with their mouth shapes and sounds that way, and then they'll develop spoken language with words, and they're put on different meanings to different words and communicative intents, and then they'll develop and progress their language from there. So the biggest difference in that is that a lot of AUC communicators don't see their language being used. So if they don't see or hear their language being used, some adults might expect them to be using it because it's like, well, here's your support. Use it, and that's not how it works. They have to see it first in order to have any output expected. Yeah.
Jayson Davies
And I mean, I know our speech therapist often uses the term modeling, and the same way that a parent would model for a student when they're trying to read a book and trying to model that word for them that they don't know how to pronounce. You would do that? And so how would you do that? Using an AAC device?
Mara Jonet
Yeah, so modeling, or another term for that, could be Aided Language simulation, and that's a big term that we use in AAC. And so Aided Language stimulation is really where you are modeling someone's device. So you use spoken language at the same time as their device. So you might be highlighting a symbol or highlighting a word or pressing the button, if it's on a device to model that vocabulary word at the same time that you are talking, and the more AC users see that, then the more buy in to their device they might have to expect to use it. So I like to go about you just pick a few words at a time and start highlighting those on the user's communication system in addition to your spoken language. And this should be happening throughout their day, throughout their communicative environments, and throughout communication partners. So it shouldn't just be speech therapists doing it. It should also be the teachers and parents and
Jayson Davies
the OTs, yeah. Everyone involved, everyone working with that student, gotcha. And I don't know, is there a few specific words that someone tends to start with, yes and no, mom, dad, where do you tend to start?
Mara Jonet
Yeah, so where we tend to start teaching is what's called. Vocabulary. So core vocabulary is the vocabulary that makes up 80% of your daily vocabulary in in a day. So some examples might be go like, I you, they're the really high frequency words that are used all throughout your day. So where to start when teaching children their AUC devices is that core vocabulary, and that's because it's usually the most accessible, and then it's kind of the easiest to navigate when you are modeling your sentences. And they also are, they tend to be verbs and pronouns, which are the building blocks of language and more complex sentences.
Jayson Davies
Yeah, and sorry. As you're talking, I keep hearing my speech therapist in the back of my head, because what you're just starting to say is, like the type of language, and a lot of times you hear, a lot of times what's programmed into, especially the more simple devices, from what I see is I go or I want food, rather than like I would like, a full sentence, and then you have to expand that out, but you really have to start simple, Right?
Mara Jonet
Yes, you absolutely have to start simple, and you have to establish meaning or context. So you have to establish that cause and effect relationship of those words. So go might mean go to a different place. It might mean make something go. It might mean go in your car. It means a lot of different things, so you have to establish that meaning with the word, but you have to do that starting out small with just that word, but in multiple environments, in multiple contexts.
Jayson Davies
Gotcha. Great. All right, so we are going to jump into the evaluation process in just a minute. But before we do, I just want to ask, because I think when we think of AAC, we think of any person who does not have the ability to vocalize, is there any other way, or any other potential definition that I'm missing? Missing when we think about potential users for AAC, I don't know if there is other uses for AAC out there, or, you know, just populations that tend to use AAC more than others.
Mara Jonet
So anyone is a candidate for AC? I guess a candidate for AC would be someone who doesn't have all of the spoken language that they need, or if their spoken language isn't understood by others. So even if they do have spoken language, you can still use AAC. And then for those individuals who are non speaking, they also would be candidates for AAC. So there's many, many diagnoses that would benefit from AAC. We see it a lot in autism, cerebral palsy, Down syndrome, childhood apraxia of speech. There's so many different diagnoses, but it's not limited to one population or anything, so anyone who needs to communicate, who is not accessing all of their communication would benefit from AAC. Gotcha.
Jayson Davies
All right. So I love what you guys are doing at the fanny pack therapist, because you guys are working together as a speech therapist and an OT combining together. How would you guys describe the teamwork, or the collaboration that you guys use when it comes to actually completing completing an evaluation, as we jump into that aspect?
Annabeth Knight
Yeah, so I think there's a lot of there are different levels of collaboration on therapy teams that are described in the research, and this has sort of changed over time, but they're typically categorized into multidisciplinary, interdisciplinary and transdisciplinary. So I'll start by saying that we see ourselves in our collaboration as a transdisciplinary collaboration, but multidisciplinary just simply means that there are multiple professionals on the team, and they may have common goals that they're working towards, or common goal areas interdisciplinary is where there's more of that active collaboration happening. So team members are working together towards these similar goals, and then with transdisciplinary teams, there's a little bit more of a of shared roles in working towards shared goals. So there's a little bit more of that gray area between where scopes of practice are, who's taking on which pieces and so many So, much of that just depends on the. Individual experience of the professionals that are on that team. So the role that the OT takes on might be different if they're working with a an SLP who's a new grad, versus an SLP who has the same number of years of experience as them, versus an SLP who's been in the field for 20 plus years. So we definitely work very collaboratively. We do not we're not particular about who takes on which pieces necessarily. Obviously, we're always working within our scope, you know, just legally and ethically, but we rely on each other and our unique experience to be able to just meet the needs of each unique child,
Jayson Davies
absolutely and quick side question is, is it just you two typically on this AAC team, or are there other professionals or non professionals on that team?
Annabeth Knight
So I'll say first that the client and the caregivers are probably the most important people on that team. So they're always on the team. They're always the center of that team and pushing all of the goals forward and all of the priorities forward. So they are on that team where we are working currently in the program that we're working in. Our evaluations are co evaluations with an OT and an SLP. So we're sort of those main practitioners, but we do have PTS who may be on the teams of these children as well, and so we're getting input from them as appropriate. We also are working with other OTs and other SLPs outside of our outpatient practice, and so a child who is seen by us probably has an OT and an SLP in the school, and they might have one in a hospital based outpatient facility as well, potentially. And so we need to coordinate all of that care as well. Wow, that sounds
Jayson Davies
like a lot, but another thing that you mentioned was where roles can get a little blurry, and how you guys kind of have to stay in your scope. What can practitioners keep in mind to ensure that team members are not crossing boundaries getting in someone else's role? It seems like you guys, I mean, work really well together, but sometimes that's not always the case, and some people can get a little frustrated. So how do you guys kind of make sure that people are doing their own thing or their own part, I guess
Annabeth Knight
so. I think the very first thing is establishing clear and consistent, um, means of communication with that entire team. So sitting down at the beginning and saying, okay, here are these six people on this team. Here's what our goals are. Here are the needs we need to meet. Who is going to take on each of these roles, and then it can become this dynamic conversation of you know, from the beginning, I feel like I should take on this piece with seating and positioning, because I have this experience with it, and the PT is wonderful, and they're going to help out with all of the additional gross motor pieces that we need, that the child needs to work on underlying to be able to participate and to communicate. But they don't have as much experience in seating and positioning, so this, this is the person who will take on that role. I think another thing to look at is just, you know, general scopes of practice, and to go back to those, those foundational guidelines that we can look at from our regulating bodies. But also to keep in mind that both Asha and a ot a have put out either position papers or statements on assistive technology and assistive technology teams, and particularly for clients who have complex medical profiles, they put out there that there's a lot to address. And here are all of the things they'll outline, all of the things that you need to address when you're looking at evaluating for at or AAC, and they say the team has to have these competencies in order to do this well, but they don't break down who needs to take on which particular role. So there is sort of that leeway of you know if, if an OT doesn't have as much experience in working with a child with cortical visual impairment, but the SLP has 10 years of experience, and almost all of their kids have had the eye even though they're not the one addressing it, they have a lot of great input. So absolutely, it comes down to communication, yeah,
Jayson Davies
and knowing each other's strengths and weaknesses. I mean, like you said, you learn so much on the job, and so if there is a very experienced speech therapist and a not so experienced occupational therapist. There's a lot of things where you'd probably want to either default to letting the speech therapist take on that role, or especially at least asking for their help and trying to figure out what you can learn from them. So yeah, yeah,
Annabeth Knight
that's a great that was, that was me, for sure. As a new grad at the school, and I was like, I people would be looking at me for all these answers from the OT scope. And I had some answers, but I didn't have the experience with the population to to know right away and to to know the technology. So that's a big piece of it, too. That's where experience comes in, is knowing the technology and keeping up with the changes in technology. Absolutely. And
Jayson Davies
there's always things changing. Man, with technology, it's crazy. They're always new apps, new language apps on the iPad, and they all cost $100 or more and and get pricey, and just new things to learn. So all right, let's kind of break down the evaluation process right now. I know we just talked about how sometimes things get a little blurry. You kind of take on roles that you just know because you've been doing this for a while, but traditionally, Mara, what would you say are the key speech components to an AAC evaluation that you look at? So in
Mara Jonet
an AAC evaluation, a speech therapist would definitely be looking at how a child communicates their expressive and receptive communication, and kind of doing an environmental inventory to determine the needs and the wants of the family or that child,
Jayson Davies
all right, so we're all occupational therapists listening to this podcast, so we're going to need you to break that down a Little bit expressive and receptive communication. Yes,
Mara Jonet
so expressive language refers to what you are able to express or communicate. So in an AUC evaluation that most likely will not be spoken language or it will be spoken language that needs to be supplemented. So in that SLPs are responsible for looking at how a child is communicating? Are they communicating by behaviors? Are they communicating by leading your hand to somewhere they want to go? Are they crying? What are they doing to communicate their basic needs or their basic wants? And we'll also look into how are they socially interacting? Are they playing with things, or are they demonstrating that joint attention? Or do they greet others? We'll look at kind of the whole realm of communication and expressive communication, and how the child's already doing that. And then receptive language refers to what a child can understand. So we'll look at what a child is understanding. Are they able to follow directions if they have any language? Are they able to answer any questions? Are they able to identify some objects, those all relate to understanding,
Jayson Davies
gotcha. And would you actually look at their ability to use technology? Yes,
Mara Jonet
definitely. So we would in an AAC evaluation, ideally, you would have access to a variety of materials and AAC devices or different levels of technology, and you'd be looking at their interest in it, or if they will imitate anything on the device, or if they'll start using it for a function. And in AC valuation, I will be using a multi modality communication approach myself, so I might sign some words to a child and see if they are visually attending to that or interested in signing, or if they imitate any signs, but I might pull up a device that I have right next to me and kind of model some words and see if they're interested in that, or if they they use it in the evaluation, just kind of depending on The level of the child, and then one important piece is really assuming that it's with the child, is that parent interview? Because what SLPs will also do is connect, do a parent interview to conduct an environmental inventory. So what are the needs of that family in order for communication to happen, or what environments to the child does the child go to and they need access to communication. Awesome.
Jayson Davies
And so I'm just going to follow follow up with that. Then where, where do you see? I guess, what is typical responses from the parent for that. What do parents identify as places the student needs or the child sorry, needs to communicate?
Mara Jonet
We get a whole variety of that. A lot of it is basic needs, communicating that they have to go to the bathroom, communicating that they're hungry or thirsty. That's, I would say that's probably a main one, is just communicating those basic needs. But then we've also had, you know, a child with a hearing loss who has a device that can use it to go swimming. So they want some sort of communication system to go swimming, so that evaluates. Will look totally different than any well, where a child doesn't have those basic communication needs, so it looks very different. But, yeah, all parents kind of identify different areas, and it's interesting to see what the parents interests or occupations are, because sometimes they'll relate to that.
Jayson Davies
Yeah. I mean, that's unique. I never thought about swimming, but, I mean, thankfully, you know, a lot of things are becoming more waterproof, but when you said that, my brain just started moving like into sports, into like, individual sports and group sports. I mean, being able to communicate like times that you don't even realize you're communicating, whether it be verbally or visually,
Mara Jonet
absolutely. And another one that we get a lot is that they want to see their child interact and play and communicate with their brothers and sisters. If they have siblings, they want to see their child communicating like, No, I don't like that, or throw the ball over there, or something of that sort. So we get a lot of it's just a range, depending on the family and kind of where the child's communication is already at.
Jayson Davies
Yeah, I expect that would be an important one, especially when there's behaviors going on where the kid is using fist and pushing as a behavior as a way of communicating, rather than an actual device or some other form of communication?
Mara Jonet
Yeah, absolutely. So we definitely work very closely with behavior therapists and everything like that too. They're on the team, but I believe that a lot of those behaviors are communicative for some reason. Yeah, all right.
Jayson Davies
So did we touch upon all the speech areas? I mean, I know we can only go over so many, obviously, an evaluation. Every evaluation is totally different based upon the kid individualized. But were there any other areas that you wanted to touch upon?
Mara Jonet
I think we hit all of the main ones ever evaluation is so customized and different. So I'm sure I'm forgetting a million things, but I also could go into very long rabbit hole.
Jayson Davies
So no, no doubt. And I mean as as you say that I'm thinking there's probably someone listening to this podcast that wants me to ask, What technology do you use? You use an iPad? Do you use a I don't know, whatever else is out there, DynaVox, whatever, but it's so you can't give me an answer on that, I'm sure, because every kid needs something different.
Mara Jonet
Every child needs something different, and every therapist has access to different equipment. So it really depends on where or what setting you're doing that evaluation in, because at our outpatient facility, we might have access to different apps, but we don't have dedicated devices. Or at a school, you might be only able to get one trial or loaner device to do that, and sometimes you don't even have access to any of that, because that equipment is very expensive.
Jayson Davies
Yeah, absolutely, yeah. All right, so let's move into the OT side of the evaluation. Annabeth, you've already mentioned a few things, vision, seating and positioning, energy, conservation, I'm sure there's more. But how about we go over those three what area? What key area are you looking for Envision,
Annabeth Knight
yeah, so I feel like even vision can be such a broad right. So I mean, when it comes down to it, we're assessing the vision needs of AAC users the same way as we would be for any other ot client in peds. And so you can be looking at things like Visual motor skills and looking at range of motion and smooth pursuits, and the ability to visually fixate and use binocular vision, and all of those things are really important, especially if you're looking at High Tech eye gaze. You want to have a really solid foundation in this kid be able to look at all of the different icon selections on the screen. How big can that array be? How big do the symbols have to be? Or it could be, you know, things that are as simple as, how are we going to position this device so that the child can view it? What is that going to look like for a child who uses a wheelchair and needs this device mounted? What is that going to look like? And this goes into seating and positioning. But what does that look like in different different positioning systems throughout the day too. And then just looking at those more basic components of what's their visual acuity, how does that impact symbol size and how many symbols then we can have on a screen display, and if we need to have high contrast symbols, or if we need to think about the visual saliency of the symbols themselves, do we need photo symbols? Or do we need just black and white, simple stick figure symbols? Do we need symbols at all? Are we looking at just using words so there's, there's so much that goes into it. But I feel like lots of the kiddos who I used to work with and who I continue. To work with are those kids with multiple neuromuscular conditions. So lots of them do have cortical visual impairment. So then that becomes a big pivot, too, and just looking at all the components that go into that, yeah,
Jayson Davies
I mean, it's amazing just listening to you guys. I mean, just the things that come up. I mean, I know I've seen you probably have used them applications that literally just test how many items can be on a page for that student. And it's just, literally, it's a game that the child plays to determine if they need two pictures on a screen, four pictures on the screen. I'm sure you all know about that, but yeah, it's crazy. How much is out there, and that OTs and speech therapists and at team and AAC team really do have to do. It's a lot of work, and I don't think everyone understands how much goes into it, all right, so you kind of touched upon seating and positioning slightly there. I don't know if you want to talk about energy conservation, or if there's another area that's even more important.
Annabeth Knight
I think so. Energy conservation, I think, is sort of overarching. That's something that I'm looking at all the time when I'm thinking about how the child is going to access the device. And so above energy conservation, I guess, is access and what that access method is going to look like. So when we talk about alternative access methods for like, a high tech device. Let's say we're looking at things like using switches to access the device or using eye gaze to access the device. What would be more of a direct selection, then would be using your finger on a touch screen for a device? So that's what you see lots and lots of AAC users using, if they're using an iPad system, that's sort of what's typical. And OTs also have a role there too, to look at that motor control piece and determine, Okay, if we had a key guard, is that going to increase their accuracy, or if we use a stylus, is that going to be better for them than using their finger to tap for the selection, but when you don't have those skills to use your hands to be able to access we need to look at a different method, and then that is a whole lot. I feel like I could talk for hours about everything that goes into that, but it basically comes down to that activity analysis of how they're accessing communication then, so I'm asking myself questions like, what movement patterns can this child use to access a switch, or do they have the movement patterns in their ocular their ocular motor range of motion? And then are we going to work on practicing those movement patterns and refining those movement patterns to make them more successful. Or are we looking at different accommodations and additional equipment that we can use to achieve that access? So yeah, lots of, lots of the kids that I'm working with them, I'm looking at different types of switches we can use. And when you get into that, it's looking at, okay, are they going to be using a mechanical switch or an electronic switch or a biofeedback switch, and what are the pros and cons of each of those? So I think Mara may have touched on this a little bit, but the the evaluation process is really expensive, but it's very it's an ongoing process, and I agree that I don't think that everybody truly understands everything that goes into it. And Mara and I definitely feel really strongly that you need more than a two hour evaluation. Our actual evaluation that we're billing for is probably just that first day, two hours, but we're continuing to see this child ongoing, to continue to do that evaluation, because you can't see everything or analyze everything in just that two hour period of time, and then say, Okay, here's the device you need. Get out the door. Absolutely
Jayson Davies
no, that's definitely sure. I feel like we could have you come back on for another episode. Just talk about switches. And we probably have to do it on a Facebook video, because video, because we obviously need to see every switch. So maybe one day we can do that. But all right, so let's get into what are some common outcomes and recommendations after an AAC evaluation combined. You guys have we've mentioned iPads, you mentioned some switches. What else is there that's fairly common to be used?
Mara Jonet
Yeah, there. There's a ton out there. So it really just depends on the child. Everything is individualized. And part of the world of AAC is that everything has to be pretty highly customized for that individual. So ideally, after an AUC evaluation, we would like to see we would like to have enough feature matching done so that we can determine a likely access. This method for that device, and then start them on a trial of a device. One part that I don't think I mentioned in the AC evaluation part is that we're also going to kind of look at their strengths in terms of, do they have categorical knowledge, of do they know you know nature, and in nature, you would find Trees and leaves and grass, things like that. Or do they have a strength in their motor planning? Because different applications and different language systems have either like categorical organization or a motor planning organization. So we're going to kind of tease that out, and then hopefully from there we'll get some sort of solid foundation to recommend a trial of a device.
Jayson Davies
Gotcha? Yeah, I get lost in those applications all the time, and I press the back button and I feel like I'm just in a whole new world. I'm like, Wait, where am I? What is, what is the most common one on iPad to go? Or what's it called? Proloquo to go? Yeah, Proloquo to go. My guy, I the thing is my worst enemy. There's just too many things on a screen, and Proloquo to go for me, at least. But no, I totally understand that there's just, and you talked about how much it has to be individualized for a student. And I think that's just so important,
Mara Jonet
right? There is no one size fits all with
Jayson Davies
AAC, yeah. And I would just like to see, I mean, just a picture of all the different things that you have to trial with I'm sure that picture is just a overwhelming and B worth 1000s and 1000s and 1000s of dollars, because I know technology is not cheap.
Annabeth Knight
Yeah, it is. It is a lot. And we, we don't have everything yet. We sort of, we work right now in a system where we have a lot of stuff in house. But when we have a kid coming in for an evaluation, we're trying to do during that intake process, and during that consultation process, we're figuring out, do we have everything in house for them, or do we need to work with vendors in our area to get something particular in and so if it's a particular communication device, then yes, we want to get that in as a loaner beforehand, so we can do that during the initial evaluation, just get their hands on it. And that also might be looking at like, if there's a particular kind of switch that we need,
Mara Jonet
we might be purchasing that, or we might be those are a little harder to do loans with. But what I like to say is that we're resource facilitators. So not everybody is a specialist practitioner, but as generalists, we need to be resource facilitators. So even though you don't have all of the knowledge, you need to have enough knowledge of the people to go to. And that might look like, of who the vendors are, of kind of common devices. Or applications, and just to have that general knowledge to get your resources from there.
Jayson Davies
Yeah, definitely. All right, so I have a few questions from notes that I've been taking, and you don't have these in front of you, but I want to ask you about them. And the first one, I think one of you mentioned dedicated device, and what is your take on, especially when it's an iPad, having an AAC such as Proloquo to go on an iPad, and then also having other systems such as games and academic apps on that iPad,
Mara Jonet
that is a loaded question, and my answer to that is that it absolutely depends on the user, because some children might be very distracted with other things on the iPad, and they might really benefit from only that dedicated system on their iPad. However, others might need to access leisure like Facebook or the internet or something like that, and if they can do that and communicate at the same time, then it should be all accessible in one. Insurance will have a little bit of a different story for you. They only fund dedicated devices. Oh, really, yeah. So you're not allowed to put any Well, it depends, but for the most part, you're not allowed to put any other applications on
Jayson Davies
it. Gotcha so they device. So they will authorize a purchase for an iPad, but they do not want other things on there. And I'm sure they probably have their ways of preventing you from putting other things on there if they want wanted to, but that's kind of what you're saying. Is that insurance wants that device to be. Be only
Mara Jonet
for communication. Yes, insurance interesting. Generally, there's, you know, insurance is very complicated, but yeah, generally, they want to see that the device is only dedicated to communication. But we kind of believe that once a user is proficient, they should be able to kind of take control of their ownership of that device and the other features that they can use on their device.
Jayson Davies
Yeah. I mean, the last thing we want is a kid who's really understanding how to use an iPad in his communication app to be like Rambo with two iPads on his back walking around because he needs one to communicate and one to access Facebook, like you said. So, yeah, totally okay. Just to add on to that, in our school district, we're kind of going the opposite route a little bit, because we are working with mostly moderate to severe students when we're talking AAC, and a lot of times, their assistant, sorry, not their assistive technology. Their iPad has a lot of academic games on it, and it has a lot of things that are a lot more interesting than Proloquo to go and so oftentimes, I mean, we can lock things, of course, we can put Guided Access on there, but that's a pain in the butt, because then there needs to be an adult to come over to unlock their iPad so that they can go to Proloquo to go so that they can find whatever folder that they need to do and find their their words. Yeah, I don't know if you want to speak to that. I
Annabeth Knight
would argue that if all of those apps are way more exciting than communicating, then maybe the app that they're using, like maybe protocol or whatever it is, isn't the best fit for them, or they haven't had, you know, enough experience using it yet. But I think that, I mean, I'm definitely a big advocate for having additional apps on an iPad or what, even if it's a dedicated device, like if you get a dedicated system from Toby, dynavax or Saltillo, you can get other apps and access to the internet and things on those devices as well. And they interface really well. Lots of those language systems are built to interface with Facebook or Instagram or Twitter, which could be a huge motivator, but you have to have the system unlocked in order to do and I think I mean, obviously, like Mara was saying, you have to strike that balance. But if that's the really motivating activity, then we want them engaging in those activities really motivating what they want to communicate about. And I would also
Mara Jonet
add that if those applications that are super fun that they just want to play all the time, why aren't we using that and infusing their language in it? Because you can have, if you have access to your own device, you can be modeling that language the whole time. So just like when I don't know, a child doesn't speak yet. You you label what they're doing. Oh, I see you going to the kitchen. Oh, you're opening the cabinet. You can model that language on their symbols or their system, and say you're popping the bubble. That's a blue bubble, or it's obviously not that fast, but you would model that language, and then hopefully that buy in is increased.
Jayson Davies
Yeah. I mean, all it takes is time and energy. The entire team, like we talked about earlier, the entire team needs to know the application. The entire team needs to know the device, know how to model that device, and at the same time, there needs to be enough adults, especially when we're talking about school. If you have eight kids in your classroom, all using AAC, and half of them are using Proloquo, half of them are using a different system. It can be overwhelming for the teacher, especially if there's not enough staff to help and help them model it. And so I see where that can be challenging for a teacher. I mean, it's one thing for me to model it when I'm one on one with a student in the sensory room or in the OT clinic, or if you're working on language at the table, but it's hard in the classroom. So I get that. But that also leads to the next area, which is from my understanding many people, probably a large majority of them, that get a device for AAC, I have heard stop using it as soon as if they're using in the schools, as soon as they're out of the schools, it's basically got done. Or as soon as they go home, it's in their backpack. It doesn't come out of the backpack. What do you guys think about that? How big of a barrier is that? And what can we do to help overcome that? I think it's
Mara Jonet
a huge barrier, and we see that across our outpatient clinic as well. So I think that just. General term would be the buy in, the buy in from all of the team members, the buy in from the family, the buy in from the child, is a huge barrier, and the only way to overcome that is for the child to see and hear their language being used by others, so that we're back to that modeling, and that Aided Language simulation, because that's their voice and their way of communicating. And once they see that, they'll kind of take ownership and be like, oh, yeah, I can do this, and I can manipulate my environment by using communication, but it's a team approach. So the parents have to be on board, the school has to be on board, other providers have to be on board, the babysitter, the brothers, the sisters. It's a huge team approach, and I think all you can do is advocate, advocate, advocate, and really hope that your team is collaborative and kind of willing to work together.
Jayson Davies
Yeah, and based upon what you just said, I think I already know the answer to this. But what does the treatment activities, or what does treatment in general, look like after the evaluation process? Are you teaching the child how to use the device. Are you coaching people? What does it look like?
Mara Jonet
It's all of the above. It is. So in order to expect any output or language from a child, you have to have that input first. So for the first while, you are just going to be modeling before you're going to be modeling without expectation. And that's what all communication partners should be doing, modeling without expectation.
Jayson Davies
No also
Mara Jonet
we will be doing activities that are motivating for them, to get them to communicate. And might throw in a couple communication temptations, like withholding a really motivating thing and making them say go or something like that, and reinforcing that behavior that would be, or that communication that would be, something that we also do. But then a huge part of it is setting up all of their vocabulary to make sure that their vocabulary is meaningful and arranged in a way that makes sense for that individual. But then it will also be training all members and all potential communication partners on that device, how the basic navigation functions work, how to provide that modeling, how to troubleshoot the technology, pieces of it, how to program a word that they might want in it, everything. And then, if it's a really more complex communicator, the treatment will still be extended evaluation to establish maybe a switch, a switch site, or establish that motor plan of the language, yeah, yeah. For OT, I feel like that ongoing assessment and that ongoing treatment, I guess, looks very different if it's a kid with complex communication needs that have those alternative access needs, or if it's not so, sometimes the OT will have a big role in the evaluation process and then sort of drop off in terms of having direct AAC intervention.
Annabeth Knight
But for those kids with complex communication needs, when we're when we're looking at switch access, I in my sessions and doing other switch accessible activities. So it might be switch accessible games on the computer, it might be switch activated toy. Is anything that's going to continue to reinforce that motor plan, motor plan. And I'm not only looking at that primary switch site, but for some kids, we might be using two switches for access. We want to have, you know, a primary site and then a backup site as well. That sort of gets into a whole other can of worms with just having multiple methods of communication that these kiddos can use, because if their primary one isn't working, or if they're not able to access it, like Mara was saying in the pool or in the bath every single night, Oh, wow. Doesn't mean that they don't have to communicate. So we're continuing to look at those routines and determine what else we're going to do to supplement
Mara Jonet
and also, just to add, we didn't even touch on this, and this is a whole nother trail that we could talk forever about. But OTs are very knowledgeable of the sensory system and sensory integration, and a lot of the children who use AAC might have sensory needs that need. Looked at for communication purposes, or in order to get them ready to communicate, or in order to, I don't know if they have tactile defense, defensiveness, to even like access the device. So that's like a whole nother thing that the OTs would also be doing ongoing in their treatment? Yeah,
Jayson Davies
absolutely. All right, so I had one more question that I thought of while you were both talking, and I don't know how much you'll see this, because I'm sure most of your referrals are coming from parents, because, like you said, you do that environmental checklist, and a lot of times as parents saying, my kid can't communicate in this area, in the schools, sometimes those referrals are coming from the teacher, or they're coming from a psychologist and well, I mean, to put it short, we sometimes get parents that are timid of going down the AAC realm because they think it's going to hinder the vocal aspect that is very important to parents. Parents want their kids to talk. They don't just want them necessarily to communicate, but a lot of them actually have this deep desire to have them speak verbally, to hear their voice. Have you guys experienced that? And what are your thoughts?
Mara Jonet
Yes, that is not unique to the school system. We definitely get parents coming in for an evaluation of their child. Can't communicate, and that AC conversation has to be, has to happen. It it's definitely a more tricky conversation, because you are right. A lot of parents have this just desire to hear that spoken language, and so the route that we have to approach it in is kind of giving them the research. And the research is that AAC is meant to aid and augment communication so it doesn't hinder any speech development or language development. It doesn't hinder anything. It only supports it, and only allows that to grow and fosters that communication. So I like to always recommend a more multi modality communication approach, so that, yes, we can absolutely still work on spoken language. But why don't we give them a way to communicate some needs while they're working on their spoken language? And sometimes that the way of phrasing it that way supports them a little bit in in that process, and I think it's it's more of a difficult conversation of just any parent with a child of a disability, there are going to be things that are just going to have to be relearned and re imagined? Yeah,
Jayson Davies
and I'm sure you feel the same way as I do. I mean, it's not like it's hard to imagine a parent not wanting to hear their child's voice. Of course, every parent wants to hear their child, their child's voice. I would want to hear my child's voice Absolutely. And I think that can be almost, probably a little defeating knowing that your kid is four or five, six years old, and you've never heard their voice. That's got to be tough. I mean, that probably is, in itself, its own therapy that might need to happen between the parent and a psychologist, or the parent and someone, but at the same time we I'm right there with you. I like the idea that you're talking about, you know, doing, coming at it from both sides of it. And maybe, does that look like? Potentially, maybe speech therapy services once a week to work on language and another, a different service to work on the AT device, or something like that. It
Mara Jonet
could look like that, or it could look as, you know, a whole a whole session working on all those modes of communication all at the same time. Because the more modes that you give a child, the more likely they're going to pick at least one to communicate. And I think phrasing things to parents as like, I understand that, you know you want to hear the voice, but how cool would it be if you hear I love you on the device too, or something, as long as it's meaningful communication, it's just kind of relearning that, and also, you know, facilitating our resources that we have. So let me recommend a parent support group. Let me recommend someone to help you walk through the process too, that we're kind of the jack of all trades in that initial conversation.
Jayson Davies
Yeah, and like you mentioned earlier, I mean, even if you're just a resource, you are valued. Table. So by by having the supports and knowing where to refer parents to, that's important, all right. And about that, do you want to add anything? I know you were, I could see you being animated. So I know I was.
I was just gonna say that I think that we are at a bit of an advantage sometimes in the outpatient setting, in that we can have parents involved directly in the sessions. And I know before we were talking about how this is sort of a hidden advantage of telehealth right now, is that parents are right there and so that buy in during a speech session where you are modeling spoken language and working on maybe some articulation and modeling AAC and using it when a parent can see that live happening in a session, I think it's easier for them to digest that and to understand what you mean by approaching language with multiple modalities. And those are just nice times to have those conversations too, because it doesn't just have to be a one and done conversation of like, well, this is what the research says. And so here's how we can support you. Here's some resources, but really helping them throughout that entire journey. And so in outpatient, we have that longevity, and we really we, especially for our AC users, encourage families to be involved in the sessions as much as they can be. Mara and I also take, when we're in the clinic, take lots of video of what we're doing in sessions, and we use that to give to families and to use. We'll approach it and say, like, this is for you and your family to use, so you know how to use the device. This is also for any caregivers. It's for teachers. It's for your physicians, anyone who's going to be communicating with your child. And I think that that sort of gentle approach to parent education is is valuable as well.
Jayson Davies
Absolutely no spot on. All right, great. Well, I think we got to wrap this up. We've been on here for a while. It's been great information. I love it. Thank you both for coming on. Really, really valuable stuff. I want to give you both the opportunity you guys have an Instagram page, go ahead and share what that is about and any other way, if you would like, if people have questions for you, how they can get a hold of you, if it's just Instagram
Annabeth Knight
or any other way, yeah. So I think that one of the big reasons why we started the fanny pack therapist was to be a resource like Mara was saying, We're resource facilitators, and we want to be that for our families and for other therapists. We happen to have a lot of experience in this area, and so we just get excited about a little nuggets that we can share. So on our Instagram account, which is at the fanny pack therapist, we have pretty much daily little plugs for at or AAC intervention strategies or resources or things. We've been trying out new technology, and we also have just started a blog, so we're excited about that as well. We want to have a little bit more robust information for therapists out there in the blog, and so that is available that will be live soon. And then we also have an email account where you could contact us with any questions. That's the fanny pack therapist@gmail.com and and, yeah, we're just excited. This was sort of fanny pack. Therapist is a side project that has a lot of pieces to it, and we're excited to see how it grows. We just have. We've really loved being able to create and to put things out there and to collaborate with other therapists who are doing this, we're definitely we're not the experts. We're not the only experts. There are lots of really cool resources out there and fanny packs. Big piece of it was just the 90s nostalgia that we bonded over when we first started working together.
Mara Jonet
And also just being creative and using your therapeutic use of self, we're very big advocates for using, you know yourself, as your main therapy tool, rather than bags of equipment and games and things to bring into sessions. We think that Sessions should occur naturally, and that's where AAC is facilitated in. The best is those natural communication environments.
Jayson Davies
Gotcha. Awesome. I love it. All right, guys. Well, thank you so much. Annabeth Mara, thank you so much for coming onto the show. I think there will be many, many OTs and other people, parents, speech therapists, other professionals that may listen to this episode that will find your information super helpful. Thank you for for being open to questions from other people, potentially through Instagram. It is at the fanny pack therapist on Instagram that's probably the easiest way, I think, to get a hold of them. But yeah, thank you so much for coming on. I appreciate it, and have a great rest of your evening. Thanks so much for having us. Yeah, no problem. Take care. Bye. Bye, all right. Well, one more time, I just want to give a huge thank you to Annabeth and Mara for coming on the OT school health podcast to share all that wonderful information with you. If you want to know anything more about assistive technology or AAC, be sure to check them out at the fanny pack therapist on Instagram. They also just released their blog as we are releasing this, so go ahead and Google the fanny pack therapist. I'm sure that will come up. I will also have it in the show notes, which you can click on wherever you're listening to this if you're not already on the show notes right now. Okay, so be sure to check that out. This has been episode 53 of the OT school house podcast. We will see you next time. Take care, everybody. Bye. Bye.
Amazing Narrator
Thank you for listening to the OT schoolhouse podcast for more ways to help you and your students succeed right now, head on over To ot schoolhouse.com Until next time class is dismissed.
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