9/29/16 Webinar with Jackie Sura: Teaching Communication to Students with Multiple Barriers to Communication

LoganTech was thrilled to host a webinar last week with special guest presenter, Jackie Sura, a BCBA supervisor and consultant at STEPS Academy. Jackie was one of Logan's own therapists and is a co-author of the STEPS Manual - Approach to Comprehensive Communication Training with the ProxTalker. 

Of course, we already knew the ProxTalker Modular AAC System and ProxPAD Choice Maker AAC Device were terrific AAC tools for students with multiple barriers to communication, but to hear Jackie, a seasoned, experienced SLP and ABA specialist describe how she uses them is, well, inspiring. Watch the video below to hear Ms. Sura describe her experience, and the research behind communication training for students with multiple obstacles to overcome. (Or, read a text transcription of that session below the video embedded in this post.)

Jackie also shared a wonderful video during the webinar about a girl named Emily who is making extraordinary progress using these tactics with a ProxTalker. You can watch that video on our YouTube Channel, here: https://youtu.be/3xtBfqHhc5Y.

You can also download the PowerPoint slides to follow along that way.

Watch the recorded webinar now:

Jackie Sura is currently the Consulting Director at the STEPS Academy in Northeast, Ohio. She has previously presented at the Milestones Organization Annual conference; the Annual International Technology & Persons with Disabilities Conference in San Diego, California; the Communication Matters Conference at Leeds University in the United Kingdom; and at ATIA in Orlando, FLorida. Jackie has been working with AAC devices, including ProxTalker, for students that have had previous stagnant success in academic, communication and social engagement since 2013 using a comprehensive and tangible approach in clinical, public school and home settings to achieve success. Jackie's passion to help others establish a comprehensive communication system stems from working with individuals with autism and related disabilities ranging from 2- 22 years old for the past 14 years, and from being the proud older sister of two amazing young adults on the autism spectrum.

So without further ado... Jackie Sura!

[Jackie:] Thanks so much. Hi everybody! Thanks for joining us today. I want to talk to you a little bit about some of the things that we've been doing here at STEPS, and hopefully you can take some tips and tools and bring them back to your setting. And here we go...

STEPS 2 Learning and STEPS Academy is in the Cleveland area in Ohio. We work with students in the area of Autism Spectrum Disorder and related disabilities, ages 2.5 to 22. We also have a consulting department as well, and STEPS 2 Learning is our branch for our teaching materials. It's a set of curricular guides for practitioners to use to assist those who have difficulty with traditional approaches to communication and we have made one for ProxTalker, and just kind of diving right into this: Sometimes when we are working with our students that have a lot of communication barriers, it can be like this very difficult math equation that you see on your screen right now, and that can be very difficult for us as clinicians to try to really find ways to successfully help our students learn and acquire and achieve independent communication.

We've all had students like this, where we use our usual teaching procedures and we start with our out-of-the-box ideas that don't prove to be successful either. Sometimes we change teachers, we change environments, materials, objectives, the size of the stimuli that we use... We go from tabletop to around the environment, we change our prompting, sometimes we use more or less technology trying to figure out ways to help our kiddos that have difficulty acquiring any type of communication system, and have more success but sometimes we still get results like this and we feel a little bit defeated. So what do we do and where do we go from here, when we've kind of used all of our tricks and tools that we know?

When we think about it for a second, just learning to communicate in general can be hard. An individual can't see words as they are spoken. Life is not like a comic book, so it's really hard to attach something tangible to the words that are coming out of an individual's mouth or out of their AAC device. In the English language, we have very complex syntax and grammar rules and that can be very difficult to navigate and understand when you're trying to just learn general communication. Sometimes the value of communication is not taught first, so a student cannot connect why it's important to use this new tool or this new way to communicate to others. Maybe we're also trying to work on labeling items, or teaching yes/no, or colors, or abstract concepts and for that particular student, it's still not making a strong connection. And the other thing that's difficult with communication training is that outcomes are not always immediate. I don't know about you, but sometimes I have to work on my own patience skills and this can be really hard. So how do we come up with our STEPS approach? We've had students like this, and here at STEPS we call them the 5-10%. So it's not just students that have difficulty picking up communication systems or even using picture exchange systems. They struggle with receptive skills. They also struggle in their academic programs, and we're still looking at the same objectives for building communication and acquisition for academics. The same targets year after year. So we have to figure out what is working for our students, and we felt like we were not doing well academically, or in the communication realm, but we knew that we had such great kids that wanted to learn. We just need to find a way to reach them.

So we took a step back as a team and tried to figure out what it was that needed to be done differently. When we looked at the students that we first kind of piloted our STEPS approach to communication training, our students were any age, but we found it was 10-year-olds or older that we first started to work with who had been stagnant with communication in our setting and previous settings. They had difficulty with engagement with others, and they were not making much progress in their academic skills. They were using a lot of different alternative behaviors to communicate, whether they be aggressive or self-injurious, or avoidant behavior. They were not picking up the communication tools that we wanted them to, to communicate that same message. So some of the things that might be stagnant with a learner that requires a new method or an additional way of teaching communication would be a student that has difficulty with receptive skills, matching, letter identification, number identification, colors and shapes, maybe difficulty sustaining attending in groups and in one-to-one settings for a few seconds at a time. We also had some students that for multiple years had difficulty progressing past phase 1 of PECS, and they did not attend consistently to dynamic screen devices. And that kind of left us a little bit puzzled as to what we should do with these types of students. So when we looked at our first students, they were identified as being in the intermediate grades, grades 3-5, and some of them included students that were brand new to us, but we knew that their communication and academic histories in their previous settings were stagnant. Their receptive skills were not progressing, and we used multiple modes of instruction and stimuli throughout the teaching. For one student, we would have them try to incorporate using motor movement for receptive skills, trying to get them moving so that they were using multiple modes of input to learn stimuli. We made a lot of environmental changes having a lot of sensory input in our instruction as well.

But we also knew that we had to make changes in the way that we were teaching communication. We knew that previously our students showed a lack of initiation with their previous communication system, so they were not initiating independently. There was always some prompt that was required to either get them to open a communication book, or to use an iPad, or to use some type of communication system; and they were always being left behind. There was a lack of ownership of the previous communication systems. The students didn't take them with them from one place to another, not seeing our understanding or comprehending the value that this tool had for them. And looking at proximity, too, sometimes the AAC device was not removed from the immediate proximity of the student. So we had to think, "You know, does response effort play more of a role if the student has their engaged in all this effort to just first get the device or the communication book and open it... Does that kind of play a part in a barrier for the student to learn this communication device?" So we had to kind of look at those. And so this is my kind of analogy that I have for you guys... How far would you travel to find this [remote control]? Depending on what your favorite TV show is, what sports season it is, your motivation to look really hard for this remote control is going to be different. And thinking about this, if the remote control is one foot away, you're probably more likely to look, to go grab that. If it's five feet away, that's still not too bad for your favorite show. What if it's in the kitchen? Depending on how your layout is in your living space, that might not be too bad. Or if you have to go upstairs... All this depends on your motivation and your desire to want to watch that show, how far you're willing to travel to get the remote to turn on the TV and put your channel on. But then if we think a little bit further, what if the show that you're going to turn on or that the TV is going to play isn't something you want? Are you going to go even that one foot to find it, or are you going to go find something else? Sometimes our students, when they're handed a new method of communication -- whether it be a communication exchange book with photos, words, using a tablet device, or sometimes even a ProxTalker, or looking at some of those other devices -- for them it can be like a foreign language, and if they don't fully understand it, they may not put that motivation, that extra effort. So we had to find a way to make the student really enjoy the device. Here's just another example: So what if it takes you 30 minutes to find? What if you're really tired? What if you weren't feeling that well? Those are things to think about when we're introducing new communication tools for our students.

So how do we use the STEPS approach, and how is it different? We look at the profile of user. We're not saying that our method is for every single student, but we're saying that for your students that are kind of puzzling to you, that require a more hands-on approach, this may be the right method for you. We always have a presumption of ability, that our student has the ability; we just have to change our ways to connect to the student to make communication successful for them. We are continually doing assessments and programming that is surrounding the means to successful communication, and we try to make communication concepts as tangible as possible. We look at academic content being embedded within communication training, and we introduce -- much later -- pronouns. And again, this is not for every student. This is for that 5-10% of students that we've identified within our own building that require just a little bit more and a little bit something different. When we look at the profile of user, we look at prerequisite skill areas, such as fine motor, receptive skills, visual scanning, and engagement with environment. We broke it down because we thought, you know, in order to engage with any type of communication tool -- whether it be a communication book, whether it be a dynamic device, whether it be something that you're typing with, whether it be some type of exchange of even objects -- in some way, each one of these skills is extremely important. And it's not just for communication but also for success in academics. So we try to make sure that all of our students that were using the STEPS approach, that each one of these skills were embedded not only in communication training, but throughout their entire academic day. Additional considerations for verbal students may also include the reliability of verbal speech, so just looking at some of our students that are emerging in their verbal communication skills but they still require some additional tool to help them to communicate more independently. Your skill level in each area is going to determine the type of communication mode that you're going to want to start off with for each student.

So, Presumption of Ability... This is a big thing here at STEPS Academy, as we make sure that every single one of our students knows that we believe in their abilities. Verbal ability is not equal to intellectual ability. We have a strong emphasis on the teacher and student relationship, and the belief in students' abilities should be primary in their treatment and education. We want to make sure that all students here are set up for success, and that they feel comfortable in their environment. So really having that belief in them is a cornerstone of our instruction here.

And then we're looking at Tangible vs. Abstract... Some of our individuals with differences may learn best with tangible concepts, so starting off with something that you can touch, you can see, you can feel -- like object identification, numbers, letters, shapes, and maybe even engaging in an activity. When we look at those abstract concepts, such as theory of mind, emotion identification, future and past tense, those can be difficult with our population here at STEPS Academy on the autism spectrum. And communication itself is very abstract, and when we look at trying to tie in communication to something tangible, that can be very difficult; but we found that for these students that we've identified that our STEPS approach works best with, we have to find a way to kind of break down that barrier and make the most abstract concept as tangible as possible. So in taking on that feat, this is what we're going to explain next. So we need to make sure that all of our communication concepts are tangible, that our teaching team is working with our communication team to embed all of that prerequisite skill content throughout the student's day, and we break up our pronouns, and we even break up "I" and "want" with these particular students when we're teaching communication acquisition. We also look at teaching the concept of categories using scene selection, so this may be helpful for those that struggle with a traditional grid layout or having all of your pictures or photos or line drawings laid out in a line, instead having a background picture of the actual environment and then where in the environment would you find those items. So for one student, we had a lunchbox, and he typically had similar items every day, so we were able to put, each morning, each one of his ProxTalker tags on a background of his lunchbox -- a photo of [the environment] -- and he could select what he wanted; and it would be placed in the same spot that it would be [pictured on] his lunchbox. Another great reason why we use scene selection for these learners is because they are then exposed to the real-life content and categories of their world. You can also place your pictures, your icons, your tags within the classroom environment; so it doesn't have to be on a photo background, but instead it can be on the toy cabinet, and the student can request that way. Or it can be inside the lunchbox instead of the food, and then you can exchange the tag for the food. So really putting it within the context. And if a student is not able to kind of switch the icon for the food, maybe even having that icon on the package of the food, too, so they can make that connection that this picture represents this item, having that additional tangible component.

Here's just another way that we looked at embedding targets. Specifically for one of our students using the ProxTalker, that had struggled with letter identification, on the back of the large ProxTalker tags we put a small piece of foam and then we have these raised sticker letters, which you see there. And what you can't see in the picture is each one of those letters has a specific texture, so that way we were combining multiple sensory input between being able to feel the letter, feel the texture of the letter, moving the letter from its position on the ProxTalker felt to the ProxTalker button, and then also pressing down and then hearing that audio feedback of the name of the letter. We did that with categories and even common items.

Then here's a picture of our student with the lunchbox and what you can also see with his specific device that we had to initially modify -- and it's not like this anymore -- is we had fixed for him two black areas where he would keep putting a single tag and then he would always hit the "play all" button, and we had to block off the other two buttons at first while we were working on sharpening his visuals skills. And at this point he has advanced past that, but this is a great way to start.

It's a little bit blurry, but this is what we did for a YouTube video layout. Again this was inside of the ProxTalker, and the laminated YouTube page was in place of the felt; and the student would make the selection of which video he would want to watch. And then for other students we've had little audio clips that went with that, so that they could make that connection as well.

This was our sensory room in our old facility (we've since moved on). Where each item is on the page is where each item is kept in the physical gym; so again, it wasn't in this neat and pretty row, but instead it was in the area on the page of where it would be in the natural environment.

And then here's just kind of like a snippet page in our manual of looking at each step of our communication training [which] consists of identifying those prerequisite skills that we talked about and how they can be embedded within the IEP. So these receptive, engagement, communication, visual goals that are on the IEP are also strengthening the student's communication targets so that the student is working on those prerequisite skills for communication throughout their academic day, not just during a speech session. So it's another way of having that whole team approach to building up the communication program.

We did look for these particular students' pronoun separations. The reason we did that is again because our language is extremely complex and abstract, and we were trying to come up with a way for the students to have a tangible representation of pronouns and figuring out what those signified. Sometimes you have students that misinterpret the pronouns of others to be an extension of self, so we were trying to find a way for those students that over-generalize pronouns incorrectly, how they can get a better handle on understanding where those pronouns actually fall for them. So this is what we do here. For our students we wear ProxTalker tags of ourselves so that we can learn the difference between "he" and "she", or "Miss Jackie" specifically. The student's picture of themselves is the "I" tag initially, when they're learning, and then we wear our tags around for the students to be able to communicate whichever pronoun that they're targeting as well. And then also exchanging them with students to help really make that concept more concrete for them, because it's a very difficult concept to try to master.

So then, where did we start? We looked at assessments or behaviors. We did that because we have these students that were not making progress with traditional communication training, and they were using these other behaviors to communicate especially their dislikes, so we needed to look at what was their particular reason. Was it to leave this situation, or was it because they didn't like a particular activity -- or sometimes even a person -- or was it because they wanted to gain attention, or they wanted to have a specific toy? We needed to figure out why they were communicating with their behavior so that we could figure out how to address that through the use of a new communication tool. We also wanted to find out preference of items, activity, people, because we wanted to know what the student liked. We really wanted to pair the introduction to the new devices with things that they like, so they had that motivation that they would want to have that effort to go look for. Think of that remote control... If you knew it was a show that you wanted to watch, you're going to look for that remote control for a while. So we wanted our students to use these devices as a tool to get those things that they wanted. And then we also assess those prerequisite skills and fine motor, visual, receptive skills, and engagement to see where we needed to tighten up and build upon those skills. And we needed to also look at everything else we've ever done with the students and review interactions with others. Was it reciprocal, or did this student need to work on more environmental engagement? So these are kind of those questions that we ask before we start our programming.

So here's some more examples... So visual... Here's an example [where] we were looking to see: Does this student make a choice with two preferred items? If it's yes, then that's great; we can increase the amount of stimiuli we put in a communication training. If the answer is no, then we start off with a single item. Do they attend the common objects that are not reinforcing? That just lets us know where we can start with stimuli. Receptive... Will they come to an instructor and engage in a presented task, with the expectation of receiving reinforcements? So do they already know, "If I do some work I will get a preferred item"? Will they engage in a preferred activity in response to a directive? So do they have limits and boundaries in understanding when they can engage in something that's fun, or is it something that they want to do all the time? So this just helps us with that initial programming. Engagement with environment... Do they take a preferred item when presented? Do they take a common object when presented? And fine motor... Do they complete non-connecting puzzles, or connecting puzzles? Do they make a mark on a paper with a writing instrument? Again, these are just examples; this is not the end-all be-all. And depending on the student's answer lets us know, again, how to set up our programming for success. And then establishing the relationship with the student... So this is, again, that foundation for success, especially here at STEPS Academy. The relationship between the instructor and the student must be comprised of respect, initially centered around the student interest. So, reciprocal -- it's not centered around demands -- and really try to establish that instructor as a preferred person. So that way the student can feel comfortable with the instructor and also be willing to complete tasks as those demands increase as well. This can take weeks, and it's not done overnight; but it can be done in conjunction with initial teaching, especially when we're working on communication and introducing a new tool for the student to use to communicate.

Here at STEPS academy, we have seven guiding principles that we use, that drive all of our instruction. Here's some additional principles... We are really striving to educate others on the importance of using, responding to, and engaging with alternative communication modes, and engaging sometimes in the same AAC use while working with the student. So if we have a student that is using the ProxTalker, we may be using a ProxTalker right with them, using that to communicate with the student and letting them see us use it to communicate our messages as well; it's extremely important. And just a little bit more in establishing that relationship, having that presumption ability, using positive language, we give tests and instruction, we have activities that we presented we offer choices, we offer technology options as well, making sure that the student knows that we see that they have abilities, not barriers.

So before we jump to [Q&A], I do want to show you a video that I have put together with a student that started using the ProxPAD -- no, sorry, ProxTalker -- and has progressed in these last few months using a tangible approach, and has become a lot more independent. So give me a second, and I'll jump to questions after that...

[Start Video] 
(Watch on YouTube! https://youtu.be/3xtBfqHhc5Y)

When we first met Emily, she was being taught to use switches to communicate mostly during her snack times. Emily didn't seem to have a meaningful connection with communication to others, but we knew she had a lot to tell us. We needed to find the right tools to help her. For Emily, she needed a hands-on, tangible way to make connections with communication. We chose the ProxTalker because we were able to make three-dimensional tags that had voice output. This really helps make language come to life for Emily. We started with basic requests to get Emily familiar with the system. Our teachers would show her two items that we knew she liked. Once she chose what she wanted by tapping the item, she was immediately given the corresponding 3D tag and prompted to place the tag on the device to make voice output. This worked well to introduce the concept of a communication exchange, but it wasn't enough for Emily to initiate.

We quickly changed our teaching method. We added shorter sessions that were about 3 minutes in length, more frequently throughout the day. We kept the tags of 2 choices on the device for Emily. We would tell her what each of the choices were on the ProxTalker. When Emily would reach out to touch a tag, we provided a prompt to help her push the tag down to create the voice output. We saw just after a few trials that Emily was making the connection. She was reaching out on her own to touch the tags to tell us what she wanted. She would choose tags that were both in the left and right positions, especially if it was for pretzels. We would rotate the tags out and bring in new choices every 4-5 trials, so that she could learn more tags. Emily is happy when she has her time throughout the day to use her device.

Communication is becoming meaningful for her.

[End Video]

[Jackie:] OK, so I'm going to try to switch back my screen, so just give me a second to... Here we go. So any questions? Anything that you guys would like to share?

[Moderator:] Thank you so much, Jackie. That was wonderful. So Jackie, while everyone is thinking, what are some common questions that you get regarding your work?

[Jackie:] Yeah, so especially when I make a presentation similar to this, I think everybody's first fear is that each one of the students will be only on this particular "Prox-" device. And out of the students that we had in our initial research trial that we presented at CSUN and at Leeds University, three out of those four students have already moved on to tablets for communication, and for other students that may have started off at a similar path as Emily, they have transitioned to pictures and more of that 2D and 1D, so there is progression, and the goal is always to move to the most universal communication method. It's just some of our students require a jumpstart. So they need to use a different type of tool to make that connection and then they're able to move on. So for one of our students, within just three months of being exposed to ProxTalker, even without using the the grid layout, or the scene selection layout, was able to just jump right to an iPad and just completely take off. We had another student that their progression took a little bit more, but now they're independently using an iPad. And for another student, they are still on the ProxTalker, but it's been embedded across all of their academics, in social interactions as well, and where some of it used to be all 3D tags, we have a lot more pictures instead of three-dimensional objects. And the really cool thing about using this for a tangible approach to communication is that it allows the students to make that extra connection of what they are trying to say and what this symbol is supposed to represent. And for other students where we used a similar alternative approach using devices, we had one student that had previously been exposed to an iPad in their school district for a very minimal amount of time but didn't make a lot of progress, and then we just changed the layout of a NovaChat for them, so it was at first all in scene selection, and within one minute he was navigating independently and he is being evaluated now for LAMP. So sometimes it's just trying to find that different way to present the same information that allows the student to kind of jumpstart, than if we had done a more traditional method. We also found the original study was more to do with just introducing a ProxTalker as communication using a modified PECS protocol to reduce stereotypical behavior -- a lot of hand slapping or vocalizations -- and it worked, but then all this other stuff came from it. So I don't want people to think that they're always locked into a device that can be limiting, but it really increases a student's opportunities, sometimes taking a couple steps in a different direction before launching into a more universal method.

[Moderator:] OK, thank you very much. I don't see any other questions coming in through the webinar, so we may leave it at that unless you have any other last things to say. Jackie, how can people look you up or find you if they're interested in learning more about your work?

[Jackie:] Oh, sure, so... My email at STEPS is "jackie@stepsconsulting.org". I also can be reached here by phone. It's 440-572-1337. And I think my twitter [handle] popped up, and that's @JackieSuraABA. I think that email popped up while I was doing our presentation here.

[Moderator:] OK, perfect. Any final thoughts or asks of the audience?

[Jackie:] Just, thank you so much!