Case Study

Case Study

Adrian is a 7 year-old boy diagnosed with autism. He attends a special class within a mainstream school where he spends all of the day in a small class of seven students.  Adrian has good fine motor skills. He used Go Talk to communicate since he was three years old but his parents changed his communication device a year ago because he appeared to be having difficulties pressing the icons on Go Talk due to his weak muscle tone.  Adrian now communicates through the use of his iPad and has been showing great improvement over the last year.

However, Adrian will not initiate conversation with his peers.  During recess or free time, he prefers arranging toy cars and colour pencils on his own.  Recently, Adrian more frequently gets upset and easily frustrated.  When he is upset, Adrian will remove his shoes, cry and screams loudly, and refuse to stand up.  The teachers need to prompt Adrian to use his communication tools whenever needed.  Adrian can write and identify his name.  He is able to write all the letters and numbers, and is currently working on identifying the letters and numbers.

Case Study- ZH

Age: 7years 8months

Assessment

ZH’s communication skills and needs were assessed using a checklist and interviews with the classroom team and her father (See Appendix A-C).

The assessment indicated the following:
•    ZH comprehends routine one part verbal instructions containing key words (or core vocabulary) with gestural support and at times partial physical prompting.
•    ZH inconsistently responds to her own name
•    ZH is able to make a choice between two real objects or remnants but is unable to make a choice between two A4 photos presented in close proximity. ZH does not respond to visuals (photos or line drawings) or written words (i.e. when shown a photo of her lunchbox during routine she will not reference the visual and does not move towards her lunchbox).
•    ZH responds to eye gaze paired with gesture (i.e. pointing), exaggerated facial expressions and vocal tone.
•    ZH primarily uses the following emerging symbolic expressive communication strategies to communicate (both individually and paired):
o    Pointing or reaching
o    Hand leading
o    Shifts in eye gaze
o    Object exchange
o    Vocalisations (short and long ‘m’ sounds)
o    Pushing away
o    Standing nearby a desired object
o    Pulling her shirt over her head
o    Crying
•    ZH started to develop communicative intent at end of 2013. Prior to 2013, she was described as a ‘passive communicator who rarely protested, requested or shared any experience’. In 2013, she primarily relied on crying and subtle unintentional behaviours that a familiar adult would interpret.
•    The following communicative needs were established by the team and ZH’s family:
o    Requesting her milk/drink
o    Requesting assistance/help
o    Requesting the toilet/change of nappy
o    Requesting regulating items/activities (when out of view)
o    Requesting more of something motivating (e.g. more pushes on the swing)
•    A focus for the team and family was to encourage ZH to persist with communication attempts. They reported that she often “gives up” if her message is not met the first time when requesting an item.

Intervention Plan

Long Term Goals-
•    ZH will be able to request desired items, objects, actions and activities using an array of communicative strategies
o    A priority is meeting her daily needs (e.g. requesting food/drink/comfort/toilet)
•    ZH will initiate communicative exchanges without adult prompting
•    ZH will be able to repair communicative breakdowns by implementing alternative strategies
o    ZH will persist with communication exchanges to achieve an outcome
•    To increase ZH’s visual literacy skills
o    ZH will respond to highly familiar A4 photos
o    ZH will select her own photo from a choice of 2
•    To increase ZH’s comprehension within routine
o    ZH will follow 1 part routine verbal instructions with minimal prompting

Behavioural Objectives

Goal: ZH will request for a drink, toilet and 1-2 motivating activities using a range of communication strategies based on the context within the classroom setting with a range of communication partners on 80% of occasions throughout the school day.

Four Levels of Independence (Behnke & Bowser, 2010 in Dell p 216) Objectives

1.    ZH will recognise real object and/or match small remnants with the real object on 90% of occasions

ZH will consistently make a choice from 2-3 real objects/remnants on 90% of occasions

2.    ZH will independently tap, hand lead or exchange the real object or remnant to make a request on 80% of occasions throughout the school day

ZH will independently make a choice from the remnant requesting board* on 80% of opportunities offered throughout the school day.

3.    ZH will independently select a remnant/object from a requesting board by tapping/touching, hand leading or exchanging with an adult OR**
ZH will give her milk flask to an adult to request a drink on 80% of occasions with a range of communication partners and across a range of classroom contexts.

ZH will independently select a remnant/object from a requesting board by tapping, touching, leading or exchanging it with an adult to request regulating activities/objects on 80% of occasions with a range of communication partners and across a range of classroom contexts.

ZH will independently select a remnant/object from a requesting board by tapping, touching, heading or exchanging with an adult to request toilet on 80% of occasions with a range of communication partners and across a range of classroom contexts.

4.    ZH will seek out and reference an adult when selecting a remnant/object from a requesting board by tapping/touching, hand leading or exchanging the object to request a drink, toilet or activity within the classroom setting on 80% of occasions with a range of communication partners.

ZH will seek out and reference an adult to exchange her milk flask to request for a drink or for “more” drink in the classroom setting on 80% of occasions with a range of communication partners.

*Requesting Board is a large canvas board, painted blue with 6 large Squares. Real objects or remnants are attached with Velcro to top of a photo of the object/remnant (See Appendix E).

**This is a multimodal approach to AAC, which in turn is targeting communication breakdown and repair. Therefore, two communication strategies are being implemented simultaneously to ensure that ZH uses the most effective communication strategy for a range of situations and contexts.

Baseline Data
Baseline data was collected via team observations (see Appendix C) and a baseline data collection form (see Appendix D).
Baseline Data indicated:
•    ZH primarily will reach for an adult and vocalize when she wants a drink. She will also touch her milk flask if it is in front of her at meal times but does not seek adult support.
•    A less familiar communication partner misread ZH’s requests on 5 out of 15 occasions. ZH attempted to repair on 1 occasion by pointing towards the object she wanted (on the other side of the room), shifting eye gaze and vocalizing
•    Class teacher and parent report that if milk flask were out of sight all day ZH would not request a drink.
•    ZH rarely requests regulating activities when out of view. If in view will independently seek them out.  ZH often requires sensory input to bring up and down her arousal levels as required. She is a passive sensory seeker.
•    ZH is toilet training and has never sought out the toilet.
•    See Figure 1-3 for baseline data.

Intervention

A Naturalistic Instructional Approach will be employed to teach ZH to request for a drink, toilet and for regulating activities/objects throughout the day. The intervention period will be over 4 weeks with data being collected throughout the day based on observations within each regular session. The classroom team will be trained by the Speech Therapist on the strategies to implement when ZH makes a request for her drink in the classroom based on information and data collected in the questionnaire and baseline data period.
Key strategies implemented include (see Appendix C for additional strategies occurring in classroom for ZH):

Modelling
•    Adult to touch/tap/ remove remnant/object from requesting board (see Appendix E) before providing ZH with her choice.
•    Adult modelling of object exchange of milk flask and remnants/objects from requesting board.

Incidental Teaching/Environmental
•    Follow ZH’s lead
•    ZH’s milk flask kept in classroom drink bottle box, which is accessible and in view throughout the day.
•    A pair of underwear next to the door where the A4 visual of toilet is kept.
•    ZH must cross the room to access the flask/motivating and regulating activities during lesson times. Therefore, an object/remnant requesting board will be set next to ZH’s seat. This will remain next to her throughout the day so that if she seeks a drink, toilet or regulating activities during lessons the adult can model or demonstrate how to use requesting board to make a request. The requesting board is also a key part of developing ZH’s ability to request for items that are out of sight.
o    ZH’s Object/Remnant Requesting board contains–
?    Cup  – for a drink
?    Puzzle piece’ – for puzzle
?    Empty mini play doh tube – for play doh
?    Empty vanilla essence bottle – for sensory smell box
?    Underwear – for toilet
o    Large A4 photos of objects on requesting board will be on requesting board (behind objects) for an adult to refer to and label.
•    Adults to label ZH’s request verbally once an object exchange or ZH has tapped/touch a remnant/object has occurred.
•    When a choice is made or an object exchange has occurred, adult to label choice, touch or remove object and immediately reinforce by providing her with a drink of milk, regulating activity or taking her to toilet. All prompts to be faded gradually.
•    All spontaneous requests using requesting board, object exchange or hand leading will be met immediately by providing ZH with her milk/regulating activity/toilet and verbal praise with exaggerated facial expressions and tone.

Prompt Hierarchy
1.    Adult model
2.    Hand over hand/Partial physical prompts
3.    Close proximity
4.    Gesture (pointing/holding hands out, palms up)
5.    Shifting of eye gaze (from ZH to requesting board/real object)
6.    Pauses (and wait for ZH to repair)

Data will be collected throughout each session in regards to:
o    Spontaneous initiation at these times
o    Spontaneous method of communication
o    Level of prompting to use goal communication strategies and/or model
o    Anecdotal observations
Timeline

Term 2, Week 1    Baseline Data
Term 2, Week 2    Week 1 Intervention
Term 2, Week 3    Week 2 Intervention
Term 2, Week 4    Week 3 Intervention
Term 2, Week 5    Week 4, Intervention
Term 2, Week 6    Assignment to be completed

See appendix D for data collection sheets (baseline and intervention)

Results and Conclusion

Over the intervention period a few notable changes occurred in the way in which ZH communicated her message.  Overall, an increase in initiation of requests was seen, in particular requesting for regulating input (see Graph 1). Unfortunately there was no increase in her spontaneously requesting for the toilet. When unprompted ZH wet her pants. The results are discussed.

Figure 1 Frequency of Spontaneous Requests
Requesting for a Drink
Overall, a slight increase in the number of spontaneous requests for drink was noted during the study (see Figure 1). Prior to intervention, ZH’s primary method to request a drink was to reach for an adult and vocalise (see Figure 2). However, as the intervention was implemented ZH started to reach for the object and lead the adult to the object more frequently and reaching for an adult and vocalising decreased from four occasions during baseline to two occasions in the final week of intervention. In week two-four of intervention ZH independently used object exchange from her remnant/object requesting board to request once each week. Adult modelling occurred eight times during first week of intervention using the requesting board before being faded. ZH continued to require gesture and close proximity to consistently use the requesting board to request for a drink.

However, ZH had more success with using object exchange to request a drink. This occurred primarily during meal times, with one exception. She required hand over hand prompts during weeks one and two but by week three she was confidently using hand leading and/or reaching for the object. By week four of intervention, ZH used object to exchange to request a drink on seven occasions (Figure 2). However, ZH was able to use tapping/touching and object exchange of items on requesting board or object exchange on 52% of occasions by week four. Therefore, this skill was not entirely mastered as per the objectives as ZH continued to require additional prompts to use her requesting board and object exchange. To ensure generalisation and to avoid ZH learning the routine with particular adults a range of adults, including unfamiliar adults, participated in this case study. Interestingly, ZH was able to use object exchange with a range of adults but tended to have most success using the requesting board with a familiar adult.

As a result intervention should be continued until ZH achieves this on 80% of occasions consistently for a minimum of two weeks before moving to the next step. The next step for ZH would be working towards maintaining object exchange and moving towards picture exchange from ZH’s requesting board.

Figure 2 Spontaneous Communication Mode used to Request a drink (no prompting used)
Requesting Regulating Input
The biggest changes in ZH’s communication occurred in the frequency and method of requesting regulating activities. During the baseline period, ZH only requested regulating activities twice (Figure 1). However, by week four of intervention ZH spontaneously requested regulating activities or objects twenty three times during the week. Prior to intervention, ZH had no method of requesting specific regulating activities or objects as these are often kept in the cupboards and only brought out when ZH showed signs of dysregulation or required sensory input. During the baseline period ZH requested ‘puzzles’ twice, once by standing nearby the cupboard and the other occasion touching a puzzle that had been left out (figure 2). The introduction of the requesting board for ZH had great success; by week four the only prompting used was close proximity, which occurred on five occasions (figure 2). During the final week ZH primarily used object exchange as well as touch/tapping objects on requesting board to make requests spontaneously. She was able to use tapping/touch or object exchange on 78% of occasions during week 4 of intervention. Similar to requesting a drink, ZH should be able to maintain the use of tapping/touch and object exchange at 80% for at least 2 weeks before moving towards a picture exchange style of requesting. The use of an iPad loaded with Proloquo2go with basic four-picture screen may also be appropriate as her visual literacy skills grow. It is also important to note that ZH requested all regulating options available from her requesting board across the week, although puzzles continue to be the most preferable activity.

Figure 3 Frequency of communication mode used to request regulating activities or objects

Requesting the Toilet
Unfortunately, ZH was unsuccessful at independently requesting for the toilet during this intervention phase. Data from baseline and week one indicated that ZH was wetting her pants at either 11am or 1pm each day. At the two times each day, an adult modelled use of the requesting board by removing the underwear and taking ZH to the toilet. Adults also modelled the use of requesting board when ZH had wet her pants to indicate requesting to get changed. ZH showed no signs of when she was about to urinate and wet ZH showed little discomfort and did not seek to get changed. Therefore, there was little motivation to request to get changed or go to the toilet. During the case study ZH was in the process of toilet training and had yet to urinate on the toilet and thus was unaware that she must go to the toilet to urinate. The use of object exchange from the requesting board will be continue to be modelled to ZH as it also aids her comprehension and as her skills around toileting develop it provides an option for requesting the toilet in the future.

Seeking out and referencing adults to request
The use of prompts such as pauses, exaggerated gesture, close proximity and sabotage assisted ZH to seek out an adult consistently when requesting for a drink and regulating activities. On 3 occasions ZH was able to cross the room to gain adult attention. ZH was able to seek out and/or reference adult on 76% of occasions throughout the week. ZH continued to require additional support to sustain and maintain eye contact such as close proximity and an adult moving into her view. Ongoing intervention targeting referencing adults should continue before introducing less familiar adults into ZH’s environment.

Summary
Overall, some lovely gains were made during the intervention period. However, it is anticipated that if the intervention period were extended an additional 5 weeks greater gains would have been seen. Naturalistic intervention will continue beyond this case study to ensure gains are maintained and ZH’s skills continue to be developed.
Appendix A – Communication Checklist
Communication Checklist

Assessment Adapted from the WATI checklist, Giant Steps Functional Assessment of Expressive Communication (FAES), Giant Steps Expressive Communication Assessment and the Giant Steps Talking and Listening Assessment

Name: ZH
Date: May 2014
Assessors: Lucy Kaan, FR (teacher), DP (Educator), SR (Occupational therapist), VL (Music therapist) and CH (Father)

Receptive Language

Comprehension of Verbal Directions
Direction    Y/N
Responds to Name    Yes
Responds to 1 part routine verbal instructions with referent present     No
Responds to 1 part routine verbal instructions with referent absent    No
Responds to 1 part non routine verbal instructions with referent present    No
Responds to 2 part routine verbal instructions (Sequential)    No
Responds to 2 part routine verbal instructions (non-sequential)    No
Responds to 2 part non routine verbal instructions (sequential)    No
Responds to 2 part non routine verbal instructions (non sequential)     No

Comments: Requires gestural support to complete 1 part routine instructions containing key words.

Comprehension of Verbal Question
Question    Y/N
Simple Who/What labelling    No
Verbal Choice    No
Verbal Yes/No questions    No
Where questions
What questions within context    No
What questions about future/past events    No
Why questions    No
How questions    No

Comments: unable to respond to simple who/what questions

Comprehension of Nonverbal communication
Non verbal    Y/N
Gesture    Yes (close proximity)
Eye gaze    Limited
Facial expression    Yes
Emotion     No
Vocal Tone    Yes (angry/happy/excited)
Comments:  Understands simple gestures used in close proximity. Will follow eye gaze when adult in close proximity. Responds quickly to simple vocal tone (angry/happy/excited) but not to emotions (e.g. if another student is upset ZH does not appear to notice or shift eye gaze to other student).

Visual Literacy Skills
Visual    Y/N
Real Objects    Yes
Miniature Real Objects    Yes (can distract)
Remnants    Yes
Large Photos of object/activity    Inconsistent
Medium Photos of object/activity    No
Small photos of object/activity    No
Cartoons/animations    No
Colour drawing    No
Line drawings    No
Written words    No

Comments: ZH responded best to real objects and remnants. She tended to fiddle with small objects and visuals. ZH was unable to identify a A4 visual of herself during a routine activity from a choice of 2. ZH was unable to make a choice between to large photos (one highly preferred/familiar and one non preferred and less familiar) when held in close proximity. ZH was able to make a choice of 2 objects and 2 remnants by reaching towards the desired object.  ZH will watch preferred youtube clips on an iPad and iPhone when held by her or placed directly in front of her but is unable to attend to the interwrite board (which is 2m in front of her).

Expressive Language

Is communicative Intent present?       Yes ? No?

Does the student use:
Pre-symbolic Expressive Communication in the form of:
Yes    No
Crying (without eye gaze)    x
Dropping an item when finished with it    x
Changes in muscle tone    x

Emerging Symbolic Expressive Communication in the form of:
Yes    No
Exchanging pictures        x
Exchanging objects    x
Functional gestures        x
Intentional Pointing     x
Intentional Eye gaze    x
Head shake        x
Push a person/hand/item away    x
Intentional vocalisations with eye contact    x

Symbolic Expressive Communication in the form of:
Yes    No
Spoken language (sentences/words)        x
Written language         x
Signs/sign language         x
Language Based AAC programs        x

Current Communication Skills

Function    Always    Frequently    Often    Sometimes    Never    Current Strategy
Request Object                     x        When in view may take object to an adult, shift eye gaze and gesture towards and vocalise
Requesting Action                x        Reaches towards an adult vocalising, may use hand leading
Requesting help                x        Reaches towards an adult vocalising
Requests interaction with adult                x        Will occasionally initiate a chase game by running from an adult shifting eye gaze back and pausing
Seeks Comfort                    x    Does not seek comfort
Protests Object        x                Pushes the object away, frowning and vocalising loudly
Protests Action/Activity        x                Pushes the person away, moves away, vocalises and frowns
Shares an experience with another                x        Will reach towards adult vocalising  and then smile (though this may be a misinterpreted request)
Greets Others                    x    Does not greet (unless adult enters her space and she smiles back)
Comments on an activity                    x    Does not comment
Requests for information                    x    Does not request for information
Gives Information                     x    Does not give information
Does the student currently use an augmentative/alternative communication system? (e.g., Picture Exchange Communication System (PECS); object exchange; TOBIs; picture communication board or book; voice output devices; electronic/alternative keyboard or computer)
If yes, which have been tried?
•    Object Exchange has been encouraged
•    Picture Exchange is the current strategy in place (April 2014) with A4 photos.
•    Proloquo2go has been loaded onto her iPad (but not set up) and she has been accessing her private speech pathologists iPad with minimal success. 2013 classroom teacher reports that she was able to make a choice from 2 photos on an iPad using Proloquo2go (using another students iPad).  The 2013 classroom speech pathologist reports that she never witnessed the successful use of iPad to make a choice.
Transitions:
How does the student react to planned transitions?
•    Often relies on the environmental cues of other (i.e. others get up so she gets up)
•    Partial physical prompts to complete physical prompts to transition at times
•    Transitions best in routine
•    Does not like swimming and will happily get changed into swimmers at school, tranisiton to car but as soon as the pool is in view she gets upset
•    Gets upset when arrives at school in the morning/home in the afternoon for the first 10min of going to new environment
How does the student react to unexpected changes in the environment or schedule (e.g., changes of routine, new people, cancellation of a favourite activity, physical rearrangement of furniture, changed placement of smaller items in the room such as puzzles on the “block” shelf)?
•    Does not notice changes to changes on the schedule or changes to motivating activities
•    However, when meal table was moved across the room, she continued attempt to eat meal where table was previously (even though there was no table there!)
•    Arrived late one day and missed morning tea. Became upset at the end of the day and wanted lunchbox (as she had not had the two set ‘meal’ times)
What proactive positive supports for transition, if any, have been built in for increased student success (e.g., picture or printed schedules, visual prompts, forewarning/foreshadowing change)?
•    Visual schedule in place (for whole class) with photos
•    Forewarning for all activities (often does not attend to interwrite board)
•    Her Sensory box is transitioned with her
•    Backpack for toilet transition
Note: As a result of this assessment the use of remnants/real objects was implemented creating her own personal ‘object’ schedule to support comprehension

Other Comments from Team whilst completing this assessment tool:
•    iPad trialed in the classroom May 2014 – ZH was unable to make a choice from a highly preferred item and item of low preferences using the iPad. Did not scan either choice on all occasions.
•    A4 Photos of highly preferred items vs. low preference item trialed when making a choice. Zoe did not reference either visual or scan choices.

Appendix B – Sensory Checklist
Sensory Assessment (from the WATI)

Sensory System Hypersensitive Response / Hyposensitive Response
Touch (tactile)    Avoids touch
Aversive reaction to getting dirty or certain textures
Has trouble sitting on some rugs and upholstery
Bothered by certain clothing (socks, underwear, jeans)
Touches everything
Chews on inedible objects
Little reaction to pain
Does not react to extreme differences in texture
Movement    Avoids unexpected movement
Seeks slow movement

Cautious of anything other than walking on flat surface (e.g., avoids running, climbing, sliding, swinging)
Gets car sick
Craves physical activity
May move constantly
Enjoys spinning, swinging, rocking – without apparent dizziness
Body Positions
(Proprioceptive)
Rigid, tense, stiff, uncoordinated
May slump, slouch or stamp feet
Clumsy
Unaware of where body is in space
May seek deep pressure
Sight (visual)    May close eyes when overexcited
May be inattentive to tasks
Overreacts to bright lights
May resist going to area with colorful rug or bulletin board
Seeks out visual stimulation by throwing/spinning objects
Stares at bright lights (fluorescent lights)
Flicks fingers in front of eyes
When anxious, may have extra sensitive peripheral vision
Sound (Auditory)    Covers ears frequently

Over-reactive to both (auditory) loud (fire alarms) and soft (computer hum) sounds
Tunes out or does not respond to sounds
Turns T.V. or music loud

May speak loudly

Smell (Olfactory)    Notices and objects to barely perceptible odors both pleasant (foods/perfumes) and unpleasant
Does not react to unpleasant odors
Smell (Olfactory)    May sniff food, people, and objects (i.e., winter boots)
Taste    picky eater, strongly reacts (gags) to certain foods

May lick or taste inedible objects

May prefer spicy or hot foods

Chooses food based on texture

Multi-sensory    Avoids or becomes agitated by crowded spaces (auditoriums)
Avoids or becomes agitated by open spaces (gymnasiums)
Avoids large spaces
Avoids small spaces
Seeks small spaces (tents, under stairs, closets)

Many children are bothered by sensory stimuli to some degree, but often children with sensory differences take much longer to recover from the experience.
What sensory strategies are calming to the student? Examples:

What sensory experiences are over-arousing to the student? Examples:

Does the student have a sensory diet?
Yes ?             No ?
?Is it implemented by someone other than the student?
Yes ?           No ?
Describe the sensory diet:

Appendix C – ZH Expressive Communication Profile – May update

Student Expressive Communication Checklist
________________________________________
Student: ZH
Class: Aqua
Date of Assessment: August 2013 (Updated May 2014)
Assessor(s): Lucy Kaan and Aqua Class Team
________________________________________
The purpose of this checklist assessment is to determine the key messages an individual student needs to communicate and aims to provide strategies which can be implemented across settings to support the development of these key communication skills. These strategies may include teaching the student to communicate using a multi-modal means of communication, including verbal communication (own speech and speech generating device), functional gesture, picture or object exchange, drawing and writing.  These communicate messages are selected after observation of the student over several weeks in a range of environments, including in the classroom, in small groups, on arrival and departure from school, when on community access and when in the playground.

Expressive Communication – IN THE CLASSROOM
Communicative Message    What does it look like?    Is it appropriate?    Strategies (and updates)
I want to play with that and/or I want that to help me regulate myself    August 2013
Zoe very rarely initiates requesting an item to play with or regulating input. She enjoys completing puzzles and also has developed a love of some cause and effect musical toys. Zoe never seeks to access these items, only occasionally moving to stand near the cupboard they are located in, mainly relying on an adult pulling them out for her before moving to them.

May 2014 Update: Zoe continues to rely on adults to access her favorite toys and regulating input. She will independently access an item if it is left out but will not consistently request input or toys if they are out of view.    N    •    Support Zoe’s understanding of items out of sight be environmentally labeling the cupboard using A4 size colored photographs
•    Model touching or pointing to the photograph or object of the item before immediately giving to Zoe
•    Remnant/object requesting board with small items/bits from Zoe’s favorite puzzles and toys
•    Offer Zoe choices from requesting board (Pink) at leisure time
•    Set up object requesting board on the door where toys are kept. Start by have objects and looking for object exchange before overlaying with visuals of object before generic visuals
•    Set up object requesting board with regulating input next to ZH’s desk
•    Model the use of requesting board
I want milk    Added May 2014
Zoe enjoys drinking milk out of her flask. She rarely independently seeks the bottle and when she does she requires an adult to open and pour the milk. She will gesture towards the general vicinity of the bottle and vocalize or reach for an adults hand and vocalize. However, if the bottle is not nearby this can be misinterpreted or her message is unclear    Not Always    •    Large picture of milk Flask near Zoe (at table and near where milk is kept and attached to choiceboard)
•    Choices between cordial and milk
•    Choiceboard with cup to be kept nearby Zoe and referred to develop object exchange
•    Offer choices
•    Goal: Remnant or Object Exchange
•    Acknowledge Requests using vocalisations and gesture and direct Zoe to remnant requesting board. Point, tap or take off the milk remnant
•    Model ‘mmmmmilk’
•    Sabotage but subtly direct Zoe to her milk bottle. Use Pause, gesture and wait for her to hand the bottle to the adult
I want the toilet    Added May 2014
Zoe does not request the toilet. She is currently in the process of toilet training    No    •    Goal: Remnant or Object Exchange
•    Emphasis the bag of clothes (or underwear) which is carried with Zoe to the toilet
•    Swing tag of A4 toilet visual attached to bag. Adult to point to and label ‘Toilet’
•    Acknowledge when Zoe takes herself to the toilet and encourage her to sit.
•    Video Modelling of transition to toilet
•    Object Exchange of underwear. Underwear to be kept on an object requesting board next to ZH. Adult to touch, tap or model exchanging underwear to request the toilet.
I want     Added May 2014
Zoe has recently shown greater interest and more confidence in requesting other needs and wants (such as pushes on the swing/jumps no trampoline, food items etc)
At times, she will use eye gaze, hand leading, gesture and vocalizations. However, this is inconsistent. She primarily uses eye gaze but often her messages are not met or misinterpreted by less familiar communication partners.    Developing
•    Goal: Hand leading, gesturing and vocalisations
•    Pause, wait and use open hand gesture to prompt request
•    Use subtly prompting cues such as proximity, gesture, giving your hand to Zoe
•    Acknowledge when Zoe’s requests when hand leading, gesture and vocalisations are used.
•    Theses requests maybe for attention, to share, help, push on the swing, play with me etc
•    Label vocabulary at all times

Messages that ZH communicates
Comunicative Message    What does it look like?    Is it appropriate?    Previous Strategies
I don’t like that/want to do that    Zoe uses subtle means of communication to let others know when she does not want to do something. When very confused or when she really doesn’t want to do something her communication of ‘no’ may be more clear, including louder vocalisations. Generally Zoe is a very compliant student and is happy to do whatever is being asked of her.
May 2014 Update: Zoe’s communicative intent has increased from 2013. Zoe is expressing ‘no’ messages more frequently and confidently, by turning her back, moving away/pushing an adult away and vocalizing. Her messages are clear. She will also sit and refuse to move if she really does not want to do something.    Y    –    Encourage Zoe to more confidently communicate ‘no’ by giving her opportunities to make choices and communicate no and it is accepted
–    Model head shake for ‘no’ with clear vocal toe and facial expression
–    Continue to encourage Zoe to push an adult away and vocalize
–    When possible accept ‘no’ messages. Acknowledge her ‘no’ with vocal tone and facial expression e.g. “oh…Zoe doesn’t want. Oh no we have to…”
I want something to eat    Zoe will eat her morning tea and lunch at giant Steps within the confines of the normal routine, but does not request food at any other time unless, for example, chips are held out, When given sufficient time she will look then reach to the packet to request.
May 2014 Update: Zoe will access her lunchbox when it is in sight. As a result the lunchboxes are kept away. Zoe will stand near where lunch box kept and vocalize, looking towards an adult and gesturing for them. In the treats on seats session, Zoe will request for more chocolate by reaching towards the adult vocalizing, if that is not met, she use hand leading to direct the adult to the bag (its kept in) vocalizing  and if that does she will open the bag shifting eye gaze from her actions to the nearby adult. If she opens it she uses object exchange to request more chocolate.     N    –    Make lunchboxes available for Zoe to access at all times
–    Environmentally place a morning tea /snack visual for Zoe at the kitchen door and near the eating tables. If she touches this visual then respond by immediately giving her a small snack (?handful of chips)
–    Encourage Zoe to vocalize near where lunchboxes are kept.
–    At times meet her requests with a small snack
–    Use of remnants available in the classroom
–    Bring in visuals and use of iPad (choice making app) to start developing requesting of individual food items (highly motivating).

Support Plan Summary
Zoe very rarely initiates any communication and it is important that adults provide a number of opportunities for her throughout the day to communicate. Adults may need to do this by sabotaging an interaction, for example pausing, blocking her from accessing something, put items in view but out of reach etc.

May 2014 Update:
Zoe has demonstrated some lovely changes in her communication and has started to initiate communication more frequently. However, as her communication is so subtle her messages may be missed. It is important that adults continue to provide a number of opportunities for her throughout the day to communicate and repair breakdowns. Adults may need to do this by sabotaging an interaction, for example pausing, blocking her from accessing something, put items in view but out of reach

________________________________________If you have any questions or comments regarding the information in this report, please contact Lucy Kaan at 9879 4971 or lucy.kaan@giantsteps.net.au

__________________________

Lucy Kaan
Speech Pathologist
Giant Steps Sydney
________________________________________

Appendix D – Data Collection Forms
ZH Requesting Milk
Date: __________________
Initiates Request
Y/N*    Spontaneous Method of communication
(Prior to prompts)    Seeks out and references adult Y/N    Prompts/Supports used (to support hand leading, object exchange and/or use of requesting board)
Morning Meeting    N
—        Adult modelled tapping milk remnant on requesting board

Session 1

Y    Vocalisation and reach for adult        Close Proximity + Requesting board of remnants, Partial Physical Prompts (hand over hand)

Y
Vocalisation and reach for adult         Adult held up requesting board, Paused for 20s, shift eye gaze with vocalisation, adult tapped remnant before ZH followed adult and tapped remnant
Morning Tea    Y    Vocalisation and tapped milk container    Y    Adult held hands out in anticipation for exchange

Session 2    N    –        Adult offered requesting board of remnants, close proximity

Session 3

Lunch

Y    Stood near drink box. Vocalised and reached for milk flask    N    Adult held out hand in anticipation, Partial physical prompts by additional adult to exchange milk

Session 4

N    –        Adult offered requesting board of remnants, close proximity. ZH touched milk bottle remnant and shifted eye gaze to adult.

Comments/Additional Observations:
ZH Requesting Regulating Input
Date: __________________
Initiates Request
Y/N*    Spontaneous Method of communication
(Prior to prompts)    Seeks out and references adult Y/N    Prompts/Supports used (to support hand leading, object exchange and/or use of requesting board)
Morning Meeting

Assessment 3: Case Study. Each student will complete a comprehensive communication case study (individually or as a group assignment; collaborative in nature) on one student with a communication disability, intellectual disability, autism, or severe disability, preferably in a school setting. The case study will include two assessments, an intervention plan, implementation of the plan, and a discussion/conclusion. Each group will prepare a presentation and upload it to the course’s Moodle site for all to view. Further information appears on the attached guidelines page.
Case Study Extra Notes

1.    Moodle presentation- Summary – uploaded .
2500 words case study essay + 500 words PowerPoint
The checklist doesn’t count in the words

2.     assignment – this will accrue bonus points if completed- because it is a lot of work to do case study and presentation.
3.    Case Study Child available if no access at all to students with a communication disorder but preferable to make it relevant to your context.

You are not limited to pure AAC in this case study
•    You can teach a student to use AT
•    You can teach a student to use AAC
•    You can improve a student’s ability to communicate verbally (i.e. a communication goal) and as part of your strategies include aspects of AT or AAC

Case Study Guidelines
This assignment will give teachers an opportunity to develop skills in the assessment, planning and implementation of communicative interventions for individuals with autism/intellectual disability/severe disabilities in a natural setting. The following components of the project are required:
I.    Assessment ?• Conduct one Communication Needs survey. Samples will be provided in class, or students are encouraged to develop their own based on the setting they are assessing. ?• Conduct one Communication Abilities survey. Samples will be provided in class, or students may develop their own. ?• Interview the family, other professionals, and if possible the person with the disability in order to determine any additional information that may be helpful to you in creating an intervention plan. Be sure to include a copy of the questions and the answers or a summary of the responses. ?
II.    Intervention Plan ?• Based on the results of the assessments, students will develop a plan for improving the functional communication of the person with whom they are working. This plan should include the following: ?a. Overview of the plan, i.e., long term goals. Where do you see this student in 1, 3, 5, 10 years down the line. Based on that, what are his or her goals for communication in those settings/circumstances. ?b. Write at least one behavioral objective in correct format, at each of the four levels of independence. Make sure that the behavior itself is written in observable and measurable terms. ?c. Include a statement about the current level or functioning (i.e., baseline data; this may be taken and graphed if possible). ?d. Discuss how you plan to carry out this intervention. Include information about settings, materials, instructional strategies, and the timeline. ?e. Develop a form for use in collecting data during instruction. Examples will be provided in class or students are encouraged to develop their own format. ?
III.    Results/Conclusions ?• Discuss whether or not the student was able to reach the criteria set in the objective. If the student was able to master the skills, indicate the next step in instruction. If the student was unable to master the skills, discuss the possible reasons and alternatives that may enable future success. Be sure to include generalization and maintenance information. ?
• Include a copy of the form used for data collection.

Assessment task 3: Case Study
SPECIFIC CRITERIA
– ??+

Understanding of the question or issue and the key concepts involved
IV.    understanding of the task and its relationship to relevant areas of theory, research and practice ?
V.    clarity and accuracy in use of key terms and concepts in Communication disorders and AAC ?
Depth of analysis and/or critique in response to the task
•    depth of understanding of key AAC principles, concepts and issues explicitly raised during the course and in your follow up readings. ?
•    Intervention plan is appropriate, reasonable, and based on assessment ?
•    Results and conclusions are based on data ?
•    Generalization and maintenance are appropriately ?addressed ?
Familiarity with and relevance of professional and/or research literature used to support response
• range of research and professional literature on communication disorders to support response
Structure and organization of response
•    appropriateness of overall structure of response ?
•    clarity and coherence of organisation, including use of section ?headings and summaries to enhance readability. ?
Presentation of response according to appropriate academic and linguistic conventions
•    clarity, consistency and appropriateness of conventions for quoting, paraphrasing, attributing sources of information, and listing references ?
•    clarity and consistency in presenting tables and diagrams ?
•    clarity and appropriateness of sentence structure, vocabulary ?use, spelling, punctuation and word length ?

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