by Marci Revelli, MS, CCC-SLP (Speech-Language Pathologist); NWACS Board Member

Since the focus of this month’s topic is device trials, I decided to write about what this looks like for the variety of stakeholders. Working at Seattle Children’s Hospital, it is vitally important to make sure that both family and school team are active participants in the AAC process.  

Best Practice: We know that it is best practice to try out different AAC systems, to compare and contrast features, to make sure it is going to be a good fit. We know from our research that device abandonment is a big problem and is often because we have not provided all the steps to ensure device success, including involving all stakeholders in the process.  

Goal: What then is the goal of trying different AAC systems? Here are some thoughts to support you in your quest to run device trials for your student or client:

• Length of Time: There is no rule for how long trials should run (to the best of my knowledge). I think it depends on the child, their strengths/challenges and then barriers that exist to support that child in learning to use the system.

• Supports At Home and School: Sometimes, it seems like a slam dunk, the child is interested and engaged, uses a system appropriately to find needed vocabulary, easily learns new symbols and symbol sequences, can use it for functional communication or as a back to speech, etc. Then, the question becomes how much support will the school and family be able to provide to make sure the system is useful? I will recommend trials to make sure the system is used and useful at school and/or at home.

• Speech Generating: Sometimes, I am not sure that the child can benefit from a speech generating device as compared to other AAC systems. Perhaps the evaluation didn’t showcase the child’s typical communication or potential to use a device. I will recommend trials either at school or in the home setting or the child will return for short term therapy.

• Pre-Symbolic Communication: Sometimes, a child presents with significant cognitive delays and/or a slower learning rate. These children may be pre-symbolic but intentional communicators. Sometimes, it is the features of voice output and/or a backlit screen that actually help the child pay attention and interact with picture symbols (versus paper picture boards or Velcro symbols that the child shows no visual regard for). I will recommend trials to look for purposeful and intentional picture symbol use over time.

• Length of Need: From an insurance perspective, we want to find an AAC system that will support a child for about 5 years. This is different from looking at device use to support IEP goals because it suggests we have to predict that the system will be useful for a longer period of time.

• Insurance: Some insurance companies require trials, some don’t. Since I don’t know all the details of every insurance, I make it a practice to ensure some form of device trials have been completed. This could mean trials were run at school, in weekly private therapy, daily in the home setting, or during evaluation sessions. I do know that, in Washington state, Molina which is a state Medicaid managed care plan (MCO) has a 4-week trial requirement.

Trial Goals: I have a few different trials goals I write to document progress toward successful device use. I will select two or three of these goals. These goals are not meant to be mastered or completed. They are simply to track progress, to show that the selected system is used and useful. Below are some examples: 

• Family will use the device at least 1x/person/day. This is an easy measure to ask a family to commit to taking the device out at least 1x/day and using it.  

• Family will use Aided Language Stimulation (ALgS) to model device use 1x/person/day.

• Family will go to a selected page and offer the child choices, 3x/day.

• Child will understand and use 5 new vocabulary items that they have been unable to do using speech, sign or other low tech AAC systems. For a child who has a lot of speech and sign approximations, we show that the device will support vocabulary growth above and beyond what they are able to do at baseline.

• Child will understand and use 5 new vocabulary items for people, places or sensory/social actions. A child who only requests food/toys, for example, may not benefit from moving from something like a PECS book to a device because the child is simply transferring what they already know to a different tool. In this case, I want to set a goal that helps to determine if the child can learn new vocabulary and/or for different functions.

• Child will see, move toward, pick up and carry the system to a partner. This is a great measure for a child's “buy in”. Is the child aware that the device can be a useful tool and so seeks it out or is the system only presented to the child and so the child only learns to be prompted to use it?  This is also a partner goal because it requires the partner to change their instruction to help build the child's independent use of the system.

• Child will navigate to find vocabulary for 3-hit sequences for intentional communication. This goal is for the child who either hasn’t shown the ability to find picture symbols stored under symbol sequences or for the child who is so pokey pokey and wants to explore the device that it is difficult for them to sustain attention specific to a communication interaction. 

• Over time/trials, the child will decrease exploration and increase intentional use. This is simply a count at baseline and then post-treatment. Perhaps at baseline, the child just wants to explore and isn’t responsive to instruction. Following instruction, the child shows more intentional use. Intentional use is typically measured by having the child stop selecting vocabulary, pause, look away from the device and/or look up at the partner in anticipation of a response.

Challenges:  I recognize that I have not addressed the elephant in the room. Namely, the challenges obtaining multiple speech generating devices for trial AND the challenges of making sure that we, the SLPs, are not falling into our own biases recommending specific companies, devices or communication apps that we know best. Stay tuned for more blog posts on these topics.