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The establishment of a speech output communication system for a non-verbal child with severe behavioural… Hicks, Janet E. 1992

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THE ESTABLISHMENT OF A SPEECH OUTPUT COMMUNICATION SYSTEMFOR A NON-VERBAL CHILD WITH SEVERE BEHAVIOURALAND COGNITIVE DISABILITIES: A CASE STUDYByJanet E. HicksB.Ed., The University of British Columbia, 1986A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF ARTS IN EDUCATIONinTHE FACULTY OF GRADUATE STUDIES(Department of Educational Psychology and SpecialEducation)Faculty of EducationWe accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIAAugust, 1992©Janet E. Hicks, 1992Department oThe University of British ColumbiaVancouver, CanadaIn presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(Signature)Date August 11,1992DE-6 (2/88)ABSTRACTThis study investigates the ability of a sevenyear old non-verbal girl (Mary), who has multiplephysical and cognitive disabilities, to learn to makerequests using an electronic augmentativecommunication device (Apple IIGS computer with UnicornExpanded Keyboard). This study will show how Marylearned to use symbols combined with speech output torequest food in a natural setting, and in the absenceof suggested communication intervention pre-requisites.Data were collected during forty-three sessions,each 15 minutes long. Verbal and physical promptswere used to teach Mary to touch a photograph symbolresulting in the activation of the synthesized speech.The number of both prompted and unprompted activationswere recorded. Data were collected to determineif Mary generalized this skill to a play situation.The results indicate that Mary was able to learn tomake food selections using the communication device.Her instances of unprompted selections increased overthe duration of the study.- ii -TABLE OF CONTENTSPage ABSTRACT^  iiLIST OF FIGURES^  ivACKNOWLEDGMENTSCHAPTER 1Introduction^  1Definition of Terms^  8CHAPTER 2Review of the Literature^ 11Case Study Research  11Augmentative Communication^ 14Generalization  27CHAPTER 3Methodology^  37Purpose of the Study^ 37The Subject  37Introduction of the CommunicationSystem^  47Reliability  53Validity  54CHAPTER 4Results and Discussion^ 56Results^  56Discussion  60Augmentative Communication^ 60Symbol Selection^ 64Pre-Requisite Skills^ 65Generalization  65Future Needs for Mary  67Future Directions for Research ^ 70Summary^  71Bibliography  73LIST OF FIGURESPage Figure 1Unicorn Expanded KeyboardOverlay^  49Figure 2Cumulative Activations ofthe Unicorn Keyboard to MakeFood Choices^  59Figure 3Cumulative Activations ofthe Unicorn Keyboard to MakePlay Choices^  61ACKNOWLEDGMENTSI would like to express my appreciation to Dr.Sally Rogow for her commitment to the field ofeducation for severely disabled children, and for herassistance on this project. I acknowledge the effortsof the other members of my committee with gratitude.I would like to thank Mary and her family fortheir co-operation on my behalf. I extend myappreciation to my special education assistants fortheir support and encouragement. In particular Ithank my husband Michael for his understanding.CHAPTER 1INTRODUCTIONThis study investigates the ability of a severelyphysically and cognitively disabled non-verbal sevenyear old girl to learn to make food and activityrequests using a speech output communication device.Her success using photographs as symbols, in additionto synthesized speech to make choices will demonstratethe ability of a seriously disabled child to learnfunctional communication skills in the absence ofsuggested pre-requisite language abilities. It is thebelief of this author that speech output communicationdevices are powerful tools for the acquisition andapplication of communication skills by children withmultiple disabilities.For children with significant developmentaldisabilities, the acquisition of language andfunctional communication skills is a challenge, andone that must be faced early in a child's development.Using a language system to indicate preferences is alanguage skill that is established early in life.- 1 -Children with cognitive, physical, and/or sensoryimpairments often possess limited means of receivinginformation from their environment, and may possesslimited response systems. Such children must behelped to develop interaction and communication skillsin order to prevent the onset of "learnedhelplessness", and over dependence on caregivers."Learned helplessness" refers to circumstances whichserve to prevent disabled children from developing asense of independence and self-reliance on their ownabilities. This often results if few expectations areplaced on the child, and when needs are anticipatedand met by caregivers without initiation from thechild. Under such circumstances disabled childrenoften become overdependent on their caregivers andfail to learn that their actions and abilities caneffect change in their environment (Musselwhite,1986).It was suggested by Foss and Peterson (1981) thatthe most significant barrier to successful integrationof developmentally delayed adults into a work settingwere poorly developed communication and interactionskills, rather than cognitive, physical, or sensory- 2 -limitations.In order to facilitate the acquisition ofcommunication skills, children must be taught todevelop responses and signals that are understood byother people to promote interaction within theirenvironment. Interaction should occur in naturallystructured situations when possible (Musselwhite,1986). Intervention designed to enable children tocommunicate is an important goal of special educationprograms. Augmentative communication systems - eg.communication boards and computer assisted devices,can enable children who are non-verbal to communicate.Successful use of augmentative communication devicespermit inclusion in normal education environments, andopportunities for interaction and participation withtheir peers (Reichle & Keogh, 1986).Tremendous gains have been made in the field ofaugmentative and alternative communication technologyin the past decade. Individuals who cannot meet theircommunication needs using speech, sign language, orwriting, have at their disposal a wide variety of- 3 -electronic devices designed to enhance and augmentexisting skills. Augmentative communication systemsinclude both unaided and aided systems. Unaidedtechniques rely on the skills of the communicator touse gestures, body language, and facial expressions toconvey meaning. American Sign Language and othersigned languages are examples of unaided communicationmethods.Aided communication systems employ the use of anexternal device capable of providing a means ofcommunication. These peripherals range from simpledevices to complex computer based devices. Pictureboards, laptop computers, and dedicated speechcomputers are examples of aided systems. Thesedevices often produce some form of visual or auditoryoutput including synthesized speech, visual display,or printed words ( Montgomery, 1986; Russel, 1984).The selection and purposes of augmentativecommunication depend on several factors including: theage and abilities of the user; the limitations of thecommunication method being utilized; and the range of- 4 -situations in which the augmentative communicationuser is required to function. Shane (1986), suggestedthat the primary goal of augmentative intervention isto enable the disabled person to function asindependently and effectively as possible in his/hercommunity. Augmentative communication technologyplays an important role in the educational programs ofstudents with severe communication disabilities.Until recently, the population of childrenand adults with severe physical disabilities anddevelopmental problems has not had access toaugmentative communication technology. Thispopulation is comprised in large part of non-speakingindividuals who are considered to have severe mentalretardation, and other associated disabilities(physical, sensory, emotional, and behavioural).Locke & Mirenda (1988) observed that although manualsigning has been a communication method of choice forteachers and clinicians for several years, manualsigning is not be the most appropriate system for thispopulation. Children with physical and sensorydisabilities may not have the motor dexterity requiredfor signing - and many cannot see the signs.Romski and Sevcik (1988) noted the paucity of researchaddressing the communicative needs of severelydisabled children and adults. They suggested that therequirement of pre-requisite skills, combined withpoorly defined teaching strategies for this populationalso prevented them from having access to the neededcommunication technology. Fortunately, this situationis changing and more severely disabled individuals arebeing taught to work with complex communicationdevices.Longitudinal studies of students with severedisabilities can help to establish guidelines for theselection and use of augmentative communicationsystems. With experience in working with theseindividuals, several issues and concerns becomeimportant. An individual's ability to applyaugmentative communication strategies beyond theimmediate control of instruction has emerged as animportant issue.^Generalization is the ability touse what has been learned in non-training situationsin the presence of other stimuli and differentresponses (Odle, Wethered, and Selph, 1982). It haslong been6observed that generalization is helped when thetraining situations resemble the natural context forwhich the training has been designed.^The goal ofmany communication programs is the establishment ofspontaneous communication skills that can be appliedin natural situations. Halle (1987) proposed that ahierarchy of levels be considered in order to bridgethe gap between instructional and naturalenvironments. Natural environments have been definedas community and home settings in which communicationis necessary. Since natural environments vary fromone individual to another, it is important to explorehow generalization occurs and can be facilitated.This study investigated how one student withsevere and multiple disabilities learned to use anApple IIGS computer with a Unicorn Expanded Keyboard.This study provides both a description of aninstructional design and an analysis of the outcome.Two main questions provided the focus for thisstudy:1. Does the use of an augmentative and alternative- 7 -communication aid facilitate making choices and/orrequests?2. Will learning to make requests in one situationgeneralize to another situation?The main premise of the study was that children withsevere developmental problems can learn to operate anaugmentative communication device to make choices andrequests, and to generalize choice making to othersituations. A case study was used because it allowedfor an in-depth exploration of both the instructionaland generalization process.DEFINITION gjE TERMS,AUGMENTATIVE COMMUNICATION - A communication systemused by an individual who is unable to use speech tomeet daily needs. It can be aided (using a deviceseparate from the body) or unaided (using arms, hands,facial expression). It can range from simple tocomplex and usually displays the communicator'smessage in any combination of visual symbols, print,video screen, or synthesized speech (Montgomery,1986).DIRECT SELECTION - The fastest way to access acommunication device, the user points with a hand orfinger to the choice he/she wishes to make. Typing ona computer keyboard, or directing a beam of light on adisplay are examples of direct selection techniques(Montgomery, 1986).ADAPTIVE FIRMWARE CARD - Consisting of an internalcircuit board and external input/output box, thisdevice allows alternate input methods to be used onthe APPLE computer series, when persons cannot accessthe standard keyboard. (Distributed by AdaptivePeripherals, Seattle WA)UNICORN EXPANDED KEYBOARD - This 128 key, multi-level,programmable membrane keyboard functions as anenlarged and/or simplified keyboard for persons wholack the skills required to access a standardkeyboard. In addition the UNICORN board can beprogrammed to function as a talking communicationboard, with a variety of customized overlays.(Distributed by Unicorn Engineering Co. Oakland, CA.)- 9 -ECHO IIB SPEECH SYNTHESIZER - This device consists ofof an internal circuit card and external speaker, andwhen used in conjunction with selected softwareproduces synthesized speech. (Distributed by StreetElectronics Corporation, Carpinteria, CA).REQUESTING - For the purposes of this study requestingwas demonstrated as the use of visual searching,and/or touching a photographic symbol to indicatechoice of a food or play activity. The photo waslocated on a customized overlay on the UnicornExpanded Keyboard which activated the synthesizedspeech mechanism.GENERALIZATION - Generalization was demonstrated asthe use of visual searching and/or touching aphotographic symbol representing a play activity in asetting different from the instructional situation.CHAPTER 2REVIEW OF THE LITERATUREThe topics reviewed in this examination of theliterature include:1. Discussion of case study methodology2. Augmentative communication and its use withseverely disabled students.3. Generalization of a learned skill and/or conceptto other situations with special reference tostudents with severe disabilities.CASE STUDY RESEARCH Research on the use of case studies demonstratestheir important role in the development of the fieldof augmentative and alternative communication. McEwenand Karlan (1990) noted that case studies have serveda role in the development of many fields. Physicians,educators, anthropologists etc. keep detailed recordsregarding the course of treatment and responses oftheir patients, students, and subjects. Crystal(1986) argued for increased case study research to- 11 -strengthen the development of the augmentativecommunication field. Many professionals working withaugmentative and alternative communication users canmake a valuable contribution to the field ofcommunication technology with properly presented casestudies (Crystal, 1987).^McEwen and Karlan (1990)forcefully argued for case study research andsuggested that case studies should be made readilyavailable in professional journals.A great advantage of case study research is thatit is a medium for sharing the experiences ofpractitioners with researchers in the field ofaugmentative and alternative communication (McEwen &Karlan, 1990). According to Yin (1984), case studymethods are useful when the subjects are too few andtoo heterogeneous to choose them at random, and/orwhen the behaviour of the individual is the primaryunit of analysis.McEwen & Karlan (1990) argued that case studiescan make several important contributions to the fieldof augmentative and alternative communication. They- 12 -contribute to the development of hypotheses forfurther research (Barlow & Hersen, 1984). Case studymethodology yields a significant number of variables,and these, if carefully detailed can provide avenuesfor systematic investigation. Locke & Mirenda (1988)used a case study approach to describe an interventionstrategy designed to help a multi-disabled child touse a computer. This study illustrated that severelydisabled learners could be taught to use a complicatedcommunication device.McEwen and Karlan (1990) also suggested that casestudies could prove to be a valuable resource foreducators in the development of educational programsand selection of materials. The newness of the field,combined with the specialized technical knowledgerequired and the high cost of equipment has limitededucators' knowledge of augmentative and alternativecommunication devices (Goossens', 1989).There is a need for "well-defined, empiricallyvalidated theory" (McEwen & Karlan, 1990 p. 71) inaugmentative and alternative communication research.- 13 -As outlined by Yin (1984), case studies are helpfulwhen they represent the testing of an existing theory,or establish conditions that can result in thedevelopment of a theoretical perspective. Kazdin(1980) suggested that case studies serve to persuadeand motivate practitioners to implement new strategiesand techniques.Case study reporting is often more descriptiveand less theoretical than quantitative studies, whichmakes it easier to derive information about methodsand materials. Readers become more familiar withsubjects than is possible in multiple subject/controlgroup designs. This information is of practicalusefulness to clinicians and educators. Kazdin (1980)noted that "concrete and dramatic case studies serveto stimulate the interest of researchers and motivatethem to test and critically evaluate the claims."(p.71).AUGMENTATIVE COMMUNICATION When choosing and implementing a communicationsystem for a non-verbal learner it is important to- 14 -consider the characteristics of both the communicationsystem, and the skills of the student. Pre-requisiteskills, symbol selection, and instructional techniquesall require careful examination.It is helpful when one is able to identify apotential augmentative communicator's level ofcognitive functioning prior to the implementation ofan intervention program (Goossens', 1989). Multipledisabilities restrict and curtail physical, sensoryand communicative functioning, making it difficult tomake realistic assessments of the child's cognitivefunctioning (Musselwhite, 1986; Reichle & Keogh, 1986;Rice & Kemper, 1984). It is important to be awarethat non-verbal does not mean non-language, and thatthere are many individuals who are unable to speak,but who comprehend language. As augmentative systemswhich facilitate communication are made more readilyavailable, more realistic assessments of skills can beconducted (Mirenda and Iacono, 1990).Nevertheless, the belief persists among severalauthors that there are pre-requisite skills that- 15 -students must demonstrate before being consideredcandidates for alternative communication system use.Several authors (Bates, Benigni, Bretherton, Camaioni,and Volterra, 1977; Slobin, 1973; Cromer, 1974)suggested a link between cognitive pre-requisites suchas object permanence, establishment of anunderstanding of causality, and the ability to imitateactions and vocal patterns, as indicators of cognitivecompetence. Reichle & Keogh (1986) cited theidentification of cognitive development in languageliterature according to the Piagetian stages ofsensorimotor development. Chapman and Miller (1980)and Carrier (1976) suggested that pre-requisite skillsneeded to be taught prior to commencement of anintervention.In an investigation of symbol transparency (thedegree to which a chosen symbol resembles the objectit is meant to represent) in non-speaking,intellectually disabled people, Mirenda and Locke(1989) selected candidates based on screeningcriterion that included such pre-requisite skills asbeing able to point and, provide a consistent yes/noresponse, maintain eye gaze, and attention to task.- 16 -Sublects were classified as mild to moderatelymentally handicapped.Kangas and Lloyd (1988), Rice and Kemper (1984),Romski and Sevcik (1988), and Mirenda & Iacono (1990)questioned the validity of the assumption that thereare indeed any strict cognitive pre-requisites for theuse of aided or augmentative communication. Kangas &Lloyd (1988) reviewed the literature related tocognitive pre-requisites and communication developmentfor individuals with disabilities. While outliningthe weaknesses in the cognitive hypothesis, Kangas &Lloyd (1988) expressed their concern that theassumption of pre-requisite skills has denied childrenwith severe disabilities access to augmentativecommunication. Despite the recent research thatchallenged the validity of cognitive pre-requisitesfor the development of symbolic communication, thebelief that pre-requisites are required continues toimpact many treatment programs and influenceassessment outcomes. Furthermore, the findings ofKangas & Lloyd (1988) suggested that there are nosignificant reasons to delay communication programs- 17 -for severely disabled children, and noted that "thereare some compelling reasons for beginningcommunication intervention at a young age even ifcertain cognitive skills have not yet been attained"(Kangas & Lloyd, 1988, p219). These include the needto develop the physical and cognitive skills that willassist the child to access a communication system,facilitation of interaction between the disabled childand his/her peers and family, and the acquisition offunctional interpersonal skills. Reichle & Karlan(1985), Steckol and Leonard (1981), and Romski &Sevcik (1988) challenged the notion that cognitivecompetence is an indicator of language ability. Theseauthors also questioned the validity that there arepre-requisites to be considered before aided oraugmentative communication can be introduced.In addition to the matter of pre-requisite skillsfor aiding the communication of non-verbal learners,there is the need to consider the symbol system to beutilized. The criterion for which mode to employ, ie.manual signs, object or pictorial symbol systems,and/or speech output devices include a number of- 18 -factors such as the age of the student, the iconicityof the symbol, the physical skills of the student, andthe communication needs. Authors differ about theprocedures that could be applied in symbol selection(Hamre-Nietupski, Nietupski, and Rathe, 1985; Reichle,Williams, and Ryan, 1981; Mirenda & Locke, 1989). Ina 1985 article, Hamre-Nietupski, Nietupski, & Ratheproposed a list of factors for choosing between manualsigning as an alternative communication method and theuse of communication boards. Their list includedconsidering the motor skill requirements of thesystem. Many systems, particularly speech outputdevices, require extremely minimal motor ability.Portability of the system is important. The useof a communication board by an ambulatory childpresents some difficulty, especially if the user isexpected to generalize his/her communication skills toa variety of settings (Calculator, 1988). Anotherfactor is the training and/or knowledge required bythe communicator's audience. Manual signing requiressignificant training, and many abstract symbol systems- 19 -ie. Blissymbolics ( Mirenda & Locke, 1989) are notreadily understood by communication partners. Inaddition, the speech quality of some speech outputdevices (particularly the early versions) may bedifficult for the untrained ear to comprehend. Somecommunication systems require a constant visualdisplay. Signs and/or picture boards can be usedtogether with speech output devices as long as thelistener is within hearing range. A communicationsystem must be versatile, and applicable to a range ofsettings in order to meet the communication needs ofthe non-verbal person. The pragmatic functions ofcommunication such as requesting, initiating,commenting, questioning, and protesting need to bepossible through the communication device.Iconicity and the transparency factor is ofimportance in the choice of visual symbol(s) to beused, either with a speech output system, or as adedicated symbol board. The dimension of transparencyis the degree to which the symbol resembles the objector action that it is intended to represent ( Mirenda &Locke, 1989). Bellugi and Klima (1976) and Mizuko,- 20 -(1987) suggested a continuum of intelligibility ofsymbols from transparent to opaque. Mirenda and Locke(1989) examined eleven different symbols typesrepresenting objects, with 40 non-verbal persons.The symbols included non-identical objects, miniatureobjects, identical coloured photographs, non-identicalcoloured photos, black and white photographs, PictureCommunication Symbols, Picsyms, Rebus, Self-Talk,Blissymbols, and written words. These studiesindicated that real objects were most easilyrecognized by subjects, while Blissymbols and writtenwords were the most difficult. Keogh and Reichle(1985) used a visual match-to-sample protocol in whichsubjects were asked to match a sample with the objectit most closely represented in a visual array of twoor three objects. Results from this protocol werecompared with an auditory matching task in whichsubjects were asked to match the sample with the mostclosely representative visual cue. Keogh & Reichle(1985) concluded that the more closely the symbolsmatches the objects the easier the task of associatingthe two. Many match-to-sample procedures have beenused to examine this topic (Dixon, 1981; Sevcik &- 21 -Romski 1986; Romski, Sevcik, and Pate, 1988) and haveyielded similar results.In 1989, Rotholz, Berkowitz, and Burberryexamined the functionality of sign language andcommunication book symbols in community settings withtwo autistic youths, The symbols used were black andwhite Picture Communication Symbols from Mayer JohnsonCo. Both students used manual signs as their methodof communication, but many of the signs were poorlyformed, and were only used in the presence of schoolstaff or family members. Baseline data were collectedat a local fast food restaurant. The students usedtheir signs to communicate with the restaurant staff.The degree of assistance required by the investigatorwas noted. During this phase the investigator wasrequired to prompt the students to use their signs atthe counter, and often had to interpret the signs forthe counterperson. Communication book training used amatch-to-sample procedure, and the application of thepictures in both requesting and responding situations.The final phase of the investigation was theapplication of the communication books in the fast- 22 -food restaurant. Rotholz et al. (1989) concluded thatthe use of the communication book was easily trained(with these particular subjects), and was more easilygeneralized to a new situation than were manual signsbecause of the transparent nature of the symbols. Theauthors advocate for the use of a variety ofcommunication alternatives in the quest for theestablishment of functional communication for the non-verbal student.Blackstone (1992) also discussed the applicationof various symbol systems with individuals with DownsSyndrome. She suggested that sign language and theuse of graphic symbols on communication boards andelectronic devices may facilitate social interactionfor those with language deficits and may encourageoral language development.Murray-Branch, Udavari-Solner, and Bailey (1991)developed textured communication symbols for use withstudents with severe cognitive disabilities andsensory impairments. Tactile materials were used torepresent objects and activities. The use of the- 23 -symbols to make choices and requests was investigated.The authors concluded that the textured symbolsresulted in expanded vocabularies for the students,and an increase in their abilities to communicateeffectively. This "low-tech" system was easilyconstructed, inexpensive, and portable (Murray-Branchet al. 1991).As previously stated, studies of communicationintervention programs for children with significantcognitive impairments have focussed largely on "low-tech", symbol or sign systems, and the degree withwhich the acquisition of these communication skillsinfluenced expressive behaviours (Clark, 1981; Dennis,Reichie, Williams, and Vogelsberg, 1982; Harris-Vanderheiden, Brown, MacKenzie, Reinen, and Scheibel,1975).The application of synthetic speech outputsystems as a viable alternative for the establishmentof communicative competence with severelyintellectually impaired individuals has not been welldocumented in the literature. There are many- 24 -advantages that such systems have that would serve thecommunication needs of the more disabled communicator(Romski & Sevcik, 1988; King, 1991). The most obviousadvantage is the provision of an interface between thelistener and the speaker. Locke and Mirenda (1988)suggested that because synthesized speech isconsistent, severely disabled learners will benefitfrom the frequent, unchanging repetition of thedevice. The speech synthesizer is a powerfulreinforcer for a severely disabled learner who mayrequire the continual reinforcement of the speechsounds for communication behaviour to emerge. Becauseof the transparency of speech output devices, evenyoung and/or non-reading communication partners caninteract with the technology user ( Romski & Sevcik,1988).Rather than delaying that onset of speech (assome researchers believed in the past), electroniccommunication aids have been shown to encourage thedevelopment of speech abilities (Fishman 1987).Fishman acknowledged that technical devices canactually increase the intelligibility of potential- 25 -speech because they remove the pressure on the speechimpaired individual to speak. As the individual isable to relax, he/she is better able to developfunctional speech. Meyers (1987) supported this viewand suggested that the use of a device withsynthesized speech output allows the child to generateas many repetitions of exactly the same words orsounds as are needed for mastery. Speech output,according to Meyers (1988), allows the speaker tofunction more effectively in a wider variety ofintegrated environments (home, school, recreation, andwork). Meyers (1987), King (1991), and Fishman(1987), described speech output devices as having adual role; they serve as a functional communicationmethod, and a way to increase the credibility of thelearner in the eyes of his/her peers. The use ofelectronic "high-tech" devices empowers the disabledchild, who functions in a society where sophisticatedtechnology is commonplace.Blockberger (1986), listed seven advantages oftechnical aids with speech output.1. The user can communicate with those not familiar- 26 -with their system.2. Reduces or eliminates the need for an"interpreter".3. User can communicate with non-readers.4. User can communicate with other disabled people.5. Increases ease of initiating communication.6. Allows communication in a more conventionalpattern.7. Through the uses of technology, allowing for pre-stored messages, the speed of communication isincreased.GENERALIZATION Generalization of a skill refers to the abilityof a learner to appropriately apply the skill in acontext other than the one in which it was learned.An important part of a communication instructionprogram is the need to plan for generalization beyondthe instructional setting (Odle, Wethered, and Selph,1982; Kaczmarek, 1991). Calculator (1988) observedthat generalization of communication skills may beparticularly difficult, yet it is the goal of all- 27 -educators. Guess, Keogh, and Sailor, (1978. p.375)indicated that "it appears to be easier to establish arudimentary language repertoire in language deficientchildren than it is to teach spontaneous use of theskills in non-training situations." Kaczmarek (1990)stated that many instructional strategies havesuccessfully taught severely disabled persons tocommunicate. Their success, however, is limitedbecause the newly acquired language skills are notused in natural environments. Often language istaught in isolated settings, and efforts must be madeto provide opportunities for these new skills to beused in other settings. Hamre-Nietupski and Nietupski(1992) examined the values parents placed oneducational priorities for their severely disabledchildren. In comparison to academic and life skilldevelopment, parents placed a greater value on theacquisition of functional communication skills. Theparents surveyed believed that sufficientcommunication abilities would help their children toform friendships and other successful socialrelationships.- 28 -Odle et al. (1982) suggested there are two typesof generalizations. 1. Stimulus generalization isthe use of an acquired language skill in a differentsetting when the same stimulus is present. Forexample requesting a drink at home, in a restaurant,and/or at school. 2. Response generalizationsuggests that a similar language behaviour will beapplied in the same setting under different stimuli.They gave the example of utilizing the rule of nounpluralization.Haring and Liberty (1990) defined skillgeneralization as responding appropriately to newsettings. Educators must apply strategies thatfacilitate all aspects necessary for generalization.These include: recognition that the setting isappropriate for the skill; identification of theantecedent stimuli; and finally responding with theskill. Haring & Liberty (1990) identified threeassumptions which provided the foundation for theirresearch. The first assumption was thatgeneralization must be a target of instruction andshould be included in a student's IEP. Secondly, only- 29 -25% of the skills which are taught to severelyhandicapped students will generalize without specificintervention. The third assumption was thatassessments of student performance in generalizationsituations are necessary to make decisions about theeffectiveness of instructional techniques.Stokes and Baer (1977), in their discussion ofgeneralization strategies, suggested thatgeneralization is more likely to occur if training hastaken place with different trainers in differentsettings. Other investigators (Calculator, 1988;Brown, Nietupski, and Hamre-Nietupski, 1976; Guess andHelmstetter, 1986) emphasized the need for teachingcommunication behaviours in the setting in which theywill be used. Stokes & Baer (1977) even suggestedthat presenting different instructional materials,responses and reinforcers for the desired behaviourwill help to facilitate generalization. Espousingthis approach however, is difficult when researchdemands a degree of control on the majority ofvariables in an investigation or intervention.Hunt, Alwell, Goetz, and Sailor (1990) analyzed- 30 -the generalized effect of communication training foreach of three severely cognitively disabled students.The conversation skills of initiation and turn-takingwere probed at regular intervals. The students usedboth verbal and symbol communication (picture books).Verbal and physical prompts were used as instructionalstrategies for conversation training. Peer partnerswere used as conversation partners during theinstructional phase and the independence(generalization) phase. Hunt et al. (1990) concludedthat children with severe disabilities can besuccessfully taught to engage in meaningfulconversation and that their three subjects were ableto converse independently with new peer partners innew settings after proper skill training. The authorsindicated that over the course of the investigationthe range of topics that occurred duringgeneralization probes were typical of high schoolstudents and that a decrease in socially inappropriatebehaviours was observed. They suggested that furtherinvestigation of the complexity of topics, quality ofthe interactions, and the extension into the students'homes would be a suitable follow-up of their study.- 31 -In 1989, Alwell, Hunt, Goetz, and Sailor used aninterrupted behaviour chain strategy to teach threeseverely disabled elementary school students torequest objects in a variety of contexts. In thisprocedure an instructional session was inserted withinan individual's routine or activity. The student wasrequired to request resumption of the activity usingresponses they had been taught. During the course ofthis investigation, the settings, materials, andinstructors were varied to promote generalization.This supports the findings of Stokes & Baer (1977) whoemphasized the need for a variety of materials,responses, and settings to help facilitategeneralization. The students used a variety ofresponses including signs, gestures, and photo cards.Communicative requests measured included "drink","out", "hug", "toy", and "eat". During eachinstructional session, the investigator interrupted aroutine by failing to provide a necessary articlerequired in the routine, or by placing a needed itemjust out of reach. No prompts were used and theinvestigators waited five seconds to see if the childwould use previously taught responses to request the- 32 -Item. If no response occurred, then verbal andphysical prompts were used to model the desiredbehaviour. These prompts were faded as theinvestigation progressed. The results demonstratedthat the interrupted chain strategy was effective inestablishing simple request behaviours with severelydisabled students (Alwell et al. 1989). The authorssuggested that communication behaviours are onlyuseful to the learner if he or she is able to applythem with a variety of people and in a variety ofsettings on a daily basis.In his investigation of factors which contributeto generalization failure, Calculator (1988) discussedthe following five variables: instructional problems;lack of environmental response; replacing oneidiosyncratic system with another; mistaken focus; andmode devaluation. Instructional problems are ofcourse limitless but referred to by Calculator (1988)as the way in which the skill is taught. A skilltaught for labelling objects must not be assumed togeneralize to requesting and responding behaviours inanother setting unless this use of the skill is- 33 -specifically taught. Further evidence is supplied byReichie and Yoder (1985). In their study, fourpreschool children were taught to label objects usingpictorial communication. The subjects failed togeneralize this skill to requesting preferred objectsat play time.Lack of environmental response refers to the factthat often adult responses to children's communicationattempts, present in an instructional setting, are notpresent in other environments. Vicker (1985)recommended facilitator training for personsinteracting with alternative communication users.Calculator and d'Altilio Luchko (1983) investigatedthe effects conversational partners have on the use ofan augmentative communication devices. Although thesubject of this study was a competent communicationboard user, her attempts to communicate with others onher job site were not successful. Her fellow workersfailed to respond to her attempts and as a result, shethen made fewer attempts to initiate conversation. Aprogram of listener instruction was provided to theemployees, and once strategies for encouraging and- 34 -responding to the subject's communication attemptswere implemented, her efforts at initiation increased.The idiosyncratic nature of many alternativecommunication systems can also result ingeneralization difficulties. These can include thedegree of iconicity of the symbol system utilized, andthe quality of the speech output system. Both thesefactors contribute to the intelligibility of thesystem for partners who are not familiar with thecommunication device.Calculator (1988) suggested that sometimescommunication behaviours that are taught have littlerelevance to the learner's needs, or to educationalgoals. He recommended that the focus be the model ofinstruction rather than the communication goal.Another factor which may limit the generalizationof communication skills is referred to as modedevaluation. An individual may employ two or moredifferent systems. For example, the communicationuser may prefer to use eye gaze to answer yes/no- 35 -questions because it is faster and more easilyunderstood by familiar partners, in addition to avoice output device or communication board. If thepreferred method is devalued by the instructor, thanfrustration may be the result and communicationattempts may decrease. Reichle and Karlan, (1985)suggested that the most successful communicators arethose that use combined methods appropriately and whohave received instruction as to the appropriate use ofcontextual cues to determine the circumstances inwhich to access a particular method. Calculator(1988) concluded that instructional strategies thatincrease the likelihood of generalization behaviourshould be taught in naturally occurring situations inappropriate environments, and that multiple forms ofcommunication should be attempted and encouraged.CHAPTER 3METHODOLOGYPURPOSE OF THE STUDY The purpose of this study was to explore how onechild with severe learning problems, who is non-verbal, learned to make requests using an electronicaugmentative communication device (Apple IIGS computerwith Unicorn Expanded Keyboard).This device employs both speech output andpictures and was selected because it is easy to manageand activate, provides immediate speech feedback, andis able to be customized for specific vocabularies.The main hypotheses of this study was -1. The child would learn to make food choices usingthe communication device.2. The child would generalize this skill to makingactivity choices.THE SUBJECT The subject of this study is a seven year old- 37 -named Mary (fictitious name) who is enrolled in afull-time special education program for children withmultiple disabilities. Mary is one of nine childrenin a class staffed by one teacher and five specialeducation assistants. Mary is the oldest of threechildren. She lives at home with her family. Mary'smedical history indicates a diagnosis of spasticquadriplegia, epilepsy, and severe retardationassociated with Dandy Walker Syndrome. This raregenetic condition is characterized by the presence ofinternal cystic growths which can interfere with thedevelopment and functioning of numerous organs. Priorto the age of two years Mary had extensive surgeriesto remove cysts from her kidney, and various locationsin her brain, including the optic nerve. There hasbeen no further growth of remaining cysts to thisdate. As a pre-schooler, Mary experienced frequentand severe seizures. She was reported to be heavilymedicated, lethargic, and inactive. Mary has beenseizure free for over two years and her medicationlevels have been significantly reduced. An overallimprovement in functioning has been reported and isdescribed below.- 38 -Mary does not speak, and requires assistance forpersonal care, including dressing, toileting, bathingetc. Mary uses a wheelchair for distance mobility,however she can pull herself to a standing positionusing furniture, etc. for support. She has learned towalk using a posterior walker. Poor protectivereflexes necessitate that she wear a soft top helmetfor protection should she fall when walking outdoors.Mary's hearing was assessed when she was in pre-schooland is reported to be within normal limits. Afunctional visual assessment has not been includedgiven that Mary had complications involving her opticnerve in early childhood. Intact visual abilities areassumed.Mary's communication skills have been assessedwith observational checklists and discussions with herparents and school staff. It is not clear how muchlanguage Mary understands. She turns her head towardsinteresting sounds and visually locates the source ofa voice or sound. She recognizes her mother and otherfamily members from their voices and actively looksfor them when she hears them. Mary does not respond- 39 -to simple commands such as "come", "sit down", or"walk" , nor does she look up, or move towards aspeaker when her name is called. Mary uses a fewgestures, vocalizations, and facial expressions tocommunicate her pleasure/displeasure,comfort/discomfort, and to request food and objects.Mary is able to vocalize several consonant-vowel-consonant combinations, including "guh", "maa", "aah",and "duh".^Mary makes a low guttural sound toexpress displeasure. She pulls away from adults orchildren if she is not interested in participating inan activity with them and signals rejection by turningher head or pushing objects away. Pleasure isexpressed by hand clapping and laughter. Mary isinterested in her environment and propels herself toreach those objects and activities in which she isinterested. Often she reaches and grabs for thethings she wants, and removes obstacles by pushing,pulling, and lifting if her path is blocked.Mary prefers brightly coloured toys and objects,frequently picking them up to examine them. She can- 40 -find her preferred toys and take them out of drawersand off of shelves. She is familiar with the closetwhere her walker and bike are kept and will open thedoor to gain access to these items. Mary is gentlewith most objects and does not intentionally damagetoys, but she does enjoy tearing pages from books, andwill pull paper displays off walls if leftunsupervised. Her family reports that she will removevideo tapes from their designated spot in a cabinetand attempts to take toys from her younger siblings.Mary is able to open doors and will leave theclassroom if she is able. Her favourite destinationsinclude the nearby water fountain, the library, andthe Primary 2 classroom where she spends most of eachafternoon. Mary plays alone for short periods butprefers to be with other children. She sometimesteases them by walking away, and vocalizing, in aneffort to involve them in a chasing game. Mary canride a tricycle and knows where her bicycle is storedin the classroom. Mary knows that she needs herwalker and keeps it in sight in the classroom. Itshould be noted that Mary walks better with the walkerthan by holding an adult's hand. With more confidence- 41 -and skill it is hoped that Mary will be able to walkindependently.Mary feeds herself finger foods and can eat softfoods with a spoon. A Tupperware cup with a lid andstraw insert are her drinking implement at school.Mary has food preferences, and helps herself to food.She will not eat from her own plate if she can seesomething she likes better on the table. She eats ata low cut-out table and sits on a primary chair.Mary has been participating in a languagestimulation program (The Hanen Early CommunicationProgram -It Takes Two To Talk) in which Mary's parentsand teachers were encouraged to imitate hervocalizations, establish turn-taking routines usingher sounds and behaviours, and establish functionalcommunication behaviours. Improvement has been noted,particularly in her ability to imitate her own soundsafter an adult has initiated them. She is encouragedto vocalize a greeting when she arrives, and at homeMary is not given additional servings of food, such asmilk, yogurt, or pizza until she produces an "mmm"- 42 -sound which is expanded by her parents to "more".Mary is interested in playing in front of a fulllength mirror, and will vocalize, pat her reflectionwith her hand, and turn her head from side to sidewhile watching her reflection. Mary is helped to usegestures such as waving, and pointing but resistsprolonged hand-over-hand assistance by pulling away.Mary has also been working with a microswitch ona series of activities designed to develop herinterest in cause and effect using the Apple IIGScomputer. Progressing from battery-operated toys,Mary can use her switch to access music or animationon the computer using specially designed software.Mary finds the visual display of the computerattractive and her attention span with this activityis longer that in other situations. Mary requiresintervention to prevent her from making excessiveactivations of the switch, or from pushing it off hertable when she is finished. Mary has not yet begun touse computer programs with features such verbaldirections for activating the switch, nor has she beensuccessful with interaction software, in which two- 43 -switch users interact co-operatively, orcompetitively. In these situations Mary does not stoptouching her switch after her turn has expired.In preparation for training in the use of anaugmentative system, Mary was shown how to communicateusing 4" x 6" photographs of her favourite foods andactivities. The aim of this instruction is to enableMary to request by pointing to photographs. Examplesof Mary's photographs include: bathroom, radio,computer, milk, sandwich, and yogurt. The photos aremounted on construction paper to add strength, and arelaminated to increase longevity. Several photos aremounted directly to objects or locations. Forexample, the photo of Mary using the commode isattached to the wall in the washroom, and the photo ofMary brushing her teeth is secured to the counter inthe bathroom. A photo of her walker is positioned onthe door of the closet in which it is stored. Thisensures that all staff are able to reinforce Mary'suse of her photos. Mary's lunch-time photos aremounted directly on her table with transparent contactpaper. Mary demonstrated the most consistent use of- 44 -her photograph cards in the lunch setting. Pictureswhich represent activities outside the classroom, suchas going to the water fountain, gym, library, schoolbus, and the Primary 2 classroom, are single holepunched and attached together with a loose leaf ring.Mary's teaching assistant carries these symbols whenshe is outside the classroom and initiates their useappropriately.Mary requires both verbal and physical prompts toaccess her photos. Verbal prompts include labelingthe object or activity and saying "look at the " , or "here is the ^" , or "show methe^". Her hand is placed on the photo, andMary pats it. She sometimes uses her finger to pointbut this is not consistent. The need for physicalprompts is decreasing as Mary makes contact with thephotos independently.Mary uses photos to make choices. No more thantwo photos of activities are presented at one time.Mary is shown the objects or activities and isprompted to make her selection, using similar prompts- 45 -as described above. The photos are placed side byside on her table and are removed once she has madeher selection in order for her to receivereinforcement. Activities/objects include the radio,bubble blowing, playing with a balloon, or using theflashlight. Recently Mary has been introduced to aseries of sequence photos which represent the stepsinvolved in an activity. For example; using aflashlight involves photo cards for opening theflashlight, inserting the batteries, turning off thelights, and shining the flashlight. After selectingthe photo, Mary is helped to complete each step in theactivity.Because Mary needs a communication device thatwill allow her to make food or activity choices in avariety of situations -another system has beenintroduced. The next section includes a descriptionof how Mary is being instructed, and discusses herprogress in the use of a voice output augmentativecommunication device. Since Mary has the necessarymotor skills, the communication system selected forher consists of a Unicorn Expanded Keyboard connected-46 -to an Apple IIGS computer. External speech isprovided by an Echo IIB speech synthesizer, and anAdaptive Firmware Card permits Mary to utilize theTalking Word Board software program. When the Unicornboard is activated, text appears on the screen andsynthesized speech reinforces the text. Thisconfiguration was present in Mary's classroom prior tothe initiation of this study. The new system is moredurable and portable than a communication board.INTRODUCTION OF THE COMMUNICATION SYSTEMBased on Mary's recent success using identicalcolour photos to represent food and toy choices, itwas decided to use these symbols with the augmentativecommunication system. The meaning of such symbols aretransparent. Mary was familiar with all the fooditems selected and had previously been exposed tocolour photos of the same items. Eating is a verymotivating activity for Mary, thus lunch-time waschosen as the appropriate time to introduce theaugmentative system. An overlay for the UnicornExpanded Keyboard was prepared, and 4 squares- 47 -measuring 4" x 4" were drawn on the overlay. The fooditems selected for the study were a sandwich, milk,yogurt, and cookie. Each food picture was glued on asquare and the overlay was placed on the keyboard.The photo representing MILK consisted of Mary's whiteTupperware cup filled with milk, positioned on acontrasting yellow background. The SANDWICH photoshowed a "Cheeze Whiz" sandwich, broken into bite sizeportions positioned on Mary's plate. Similarly theCOOKIE photo showed a fruit-filled oatmeal cookiebroken into bite size pieces. Her YOGURT wasrepresented by a photo of blueberry yogurt in herbowl, with her spoon and the empty yogurt containedplaced beside it. Figure 1 shows the configuration ofthe Unicorn Keyboard.The Talking Word Board program was used toprogram the computer to name the food item when Marypressed the square. The phrase "more ^" wasprogrammed for each photograph. The Unicorn board waspresented to Mary at a slightly angled position,approximately 45 degrees to her lunch table. Thisposition was selected because it took up less space- 48 -COOKIESANDWICHBCDEF GNI^J^K L MNOP12345678AMILK'YOGURTFigure 1Figure 1 -^Reproduction of the Unicorn ExpandedKeyboard Overlay text represents placement of photographsand permitted better visual display. The angle alsomade it easier for Mary to reach for her photographs.MEASURES The procedure used was an A-B design, describedby Yin (1989). In this design a specified behaviour(in this case selection of food using an expandedkeyboard) is measured throughout two phases. Thefirst phase (A), or baseline, measures the naturalfrequency of occurrence of the behaviour (Barlow &Hersen, 1984). During the B Phase a treatment isintroduced and changes in the behaviour are recorded.The dependent variable was the number of times Maryselected a food item using the Unicorn Keyboard.Instruction took place at the table where Mary eatsher lunch in the classroom. It was felt communicationtaught in a natural setting is more likely togeneralize to other settings. All instruction wascarried out by the investigatorBaseline data were gathered by measuring thefrequency of occurrence of the dependent variable -- 50 -unprompted activation of the Unicorn Keyboard torequest food. Baseline data were obtained when Marywas introduced to the four food items, and the Unicornboard with the picture symbols she would be using.The food items were shown to Mary and she was allowedto taste each one. All attempts to touch the photos,resulting in the activation of the Unicorn board wererecorded. Instructional sessions were fifteen minuteslong. This phase continued for five sessions, when areliable pattern of measurements was established.Intervention consisted of thirty-three sessions,each fifteen minutes long. The intervention tookplace at Mary's regular lunch table positioned nearthe Apple IIGS computer in the classroom. Because ofMary's previous experience with two photograph choicesfor lunch-time, it was decided that two photographswould be offered to Mary initially. The first overlayprovided a milk and sandwich photo. Physical guidancein the form of lifting Mary's hand to touch thephotographs was performed at the beginning of eachteaching session during the intervention phase. Marywas accustomed to eating one food before making a- 51 -second choice. Usually she enjoyed beginning with adrink of her milk. Milk requests took place at thebeginning of instructional sessions. In order toassess Mary's ability to make yogurt and cookieselections from the Unicorn board, data were collectedafter she was finished her sandwich. New photographswere added to those already in place, until a seriesof three overlays were used. The position of thesymbols on the overlay remained constant for theduration of the intervention.The verbal prompt "What would you like Mary?" wasused and her choice was reinforced with thepresentation of the food item saying "Good girl Maryhere is a ^ ." A new food photograph was addedonce Mary had selected a food item four times duringeach of three consecutive sessions. The number ofprompted and unprompted touches resulting in syntheticspeech activation of the Unicorn board were recorded.Yogurt was introduced as a photo choice duringsession twenty-two. Mary particularly enjoyed eating- 52 -yogurt and did not want to make another food choice.Data collection for activation of the yogurt photolocation began when she had eaten most of thesandwich. The yogurt photo was located in the lowerleft corner of the overlay. The yogurt was given toher in her bowl and after two of three spoonfuls, thebowl was removed and verbal prompts of "What would youlike Mary?" were provided for making a request foryogurt.During session thirty-one, the final photo, thatrepresenting a cookie, was introduced.Generalization was explored by presenting Marywith a new overlay of two 4" x 4" colour photographsof two favourite play activities; bubble blowing andlistening to the tape recorder. These were mounted onthe Unicorn Keyboard in a similar manner as her foodsymbols, and any attempts to touch the Unicorn boardresulting in synthetic speech output were recorded forfive sessions.- 53 -RELIABILITY The following procedures were undertaken to ensurereliability. All procedures were documented andreported by the investigator at the conclusion of thestudy. This was done to allow for replication of thecase study. In addition interobserver reliability wascalculated by training a classroom teaching assistantto record prompted and unprompted activations of thekeyboard by the subject, using videotapes of randomlyselected sessions of all phases. The reliability co-efficient was determined by dividing the number ofagreements by the sum of the agreements anddisagreements and multiplying by 100.During the baseline phase, three sessions werevideotaped and the mean interobserver reliability was100%. During the intervention phase, ten sessionswere videotaped and the mean interobserver reliabilitywas 92%. Similarly, during the generalization phasethe mean interobserver reliability was 90% for fivevideotaped sessions.- 54 -VALIDITY In order to ensure appropriate constructvalidity, information regarding the subject of thecase study was obtained from multiple sources (Yin,1989), including reports contained in classroom files,interviews with Mary's parents, and direct observationby the investigator.The generalization phase of the case study helpsestablish credible external validity. Because it isdifficult to determine whether the results of a singlecase study can generalize to other situations,accurate reporting must occur to facilitate ease ofreplication.CHAPTER 4RESULTS AND DISCUSSIONRESULTS Over the course of this study, Mary's ability toselect a preferred food item using the UnicornKeyboard increased. Reliance on verbal and physicalprompts was reduced, as Mary made independent use ofthe Unicorn Keyboard.During the initial introduction of the keyboard,Mary was observed to activate the Unicorn Keyboardwithout prompts on only two occasions. It is possiblethat this was incidental, although she looked at thefood placed nearby on the counter. She also initiatedeye contact with the author and generally behaved in acheerful manner. She made happy sounds and clappedher hands in anticipation of eating. Mary connectedher use of the keyboard with receiving food. Shetouched the keyboard several times, patted it with herleft hand, and reached out to fiddle with the plasticprotector between bites of food. When she activated- 56 -the voice mechanism she turned to look at thecomputer. When the monitor was turned off to minimizedistraction, Mary did not appear to look at thephotos, and she activated the voice mechanism withoutapparent visual contact with her photos.The results of the intervention phasedemonstrated an increase in Mary's ability toassociate her photos, and voice activation of theUnicorn Keyboard with the food items. At thebeginning of the intervention phase, Mary requiredmany verbal and physical prompts to use the UnicornKeyboard to request. When Mary made unprompted milkrequests, sandwich selection was included. Afterseveral sessions, Mary began to make unpromptedrequests. During the intervention phase, when Marywas eating and not involved with making food requests,she made numerous attempts to handle, push, andotherwise try to manipulate the Unicorn Keyboard.Close supervision was necessary to prevent damage tothe communication device. Sandwich requesting wasfrequent, probably because she was hungry when giveninstruction on the keyboard. Mary made several- 57 -unprompted requests for milk and/or sandwich and hernext photograph was added after session twenty-one.Mary learned to access the proper location of theyogurt photograph which was at the lower left cornerof the overlay. At first, Mary made several requestsfor milk and/or sandwich and did not touch the yogurtphotograph. She was often pleased to have milk inbetween yogurt but was not pleased when given asandwich instead of yogurt.Activation of the cookie photograph wasinconsistent, due in part to the fact that Marypreferred to eat a cookie after the yogurt and onoccasion was not hungry enough to want the cookie. Atthis stage of the intervention phase, Mary madeseveral unprompted requests for sandwich but did noteat it after the request was made. During theintervention phase, Mary began to show an interest inthe photos on the expanded keyboard and made fewerincidental touches. On several occasions, Marydemonstrated a pointing response when selecting herfood choice. Figure 2 shows the increase in Mary's- 58 -140 Interventionu) 1200100+-)KC80E-:60CJ• -74020V0^ f^fTBaseline■ ^ Prompted Activations^ Unprompted Activations' i^^f^I' f^f^fFigure 2: Cumulative Activations of the UnicornKeyboard to Make Food Choices1-^f^fr,")^,f)^ L()^ )CN CV CV CV CNSessions)a-f2r-uv-11use of the Unicorn Keyboard to select food items.In each of the five generalization sessions, Maryshowed a growing ability to indicate activitypreference using the Unicorn Keyboard. At the startof each session, Mary was shown the bubble and taperecorder equipment positioned on the table next toher, and attempted to reach for her choice. She wasredirected with a physical prompt to the photograph onthe expanded keyboard and assisted to activate thesynthesized speech. This type of prompting wasrequired for each of the two activities. Marydemonstrated unprompted activation of the keyboard torequest music (fifteen times) and bubbles (fourteentimes) during the five generalization sessions. Thecumulative number of requests is shown in Figure 3.DISCUSSION OF ;INSULTS,AUONINTAT I Vi gaMEgagalmAs a result of the intervention described in thisstudy, Mary learned to request food and drink using- 60 -Figure 3: Cumulative Activations of the Unicorn Keyboardto Make Activity Choices30Generalization25D20 -151 0• _- Prompted Activations- -0 --- Unprompted Activations 50 -1^2^3^4^5Sessionsthe Unicorn Keyboard in combination with colourphotographs. Reinforcement consisting of speechoutput and the provision of requested food was foundto be a successful combination for Mary. She alsolearned to generalize this skill to a play setting,requesting activity choices using the Unicorn board.The instructional procedure using verbal andphysical prompts was important for Mary. As herability to make unprompted choices increased, herreliance on verbal prompts decreased. Maryoccasionally required physical prompts, especially atthe beginning of each session. This reliance willneed to be reduced in order for her to initiatefunctional communication.It was apparent early in the study that thespeech output was important to Mary. She would looktowards the Echo speaker when the speech wasactivated, and on several occasions, if Mary's touchdid not activate the speech, she would look towardsthe investigator and then make another attempt toactivate the Unicorn board. Mary did not however,- 62 -make attempts to correct herself if she selected asymbol that was incorrect. Instead, she refused thefood item offered and would receive prompts forselecting the desired food. This suggests thatperhaps Mary is able to associate the photos with theproduction of speech feedback and the provision offood, but is not yet able to associate only the speechoutput with her food choices. The speech synthesizerprovided an interface between Mary and theinvestigator, resulting in immediate reinforcement forMary's requests. On one occasion Mary's siblings werevisiting in the classroom and her four year old sisterbecame interested in the voice output of thecommunication system. Mary's sister was able to echothe voice appropriately and was prompting Mary to "askfor a drink", and "touch the sandwich". This interestin, and comprehension of the synthesized speech by ayoung child with no history of developmental problemsreinforces the argument that non-reading children caninteract effectively with an augmentativecommunication user (Romski & Sevcik, 1988). Theintroduction of speech output as part of Mary'scommunication skills provides her with an opportunity- 63 -to control her environment, initiating communicationwith her peers and teachers.SYMBOL SBLICTION Because Mary displayed a preference for eatingher lunch items one at a time and did not selectanother item until she was finished eating theprevious one, it may be questioned as to whether Marywas able to associate the food with the photographsymbol. The generalization procedure was importantevidence to suggest that this was not the case.During this phase Mary made selections for bubbles andmusic in a random order and was pleased with thereinforcement for her selections. In addition, whenMary was eating her yogurt and her cookie, she madeseveral unprompted requests for milk. This suggeststhat she was able to discriminate among her photosymbols.^Mary's ability to associate the photographswith the food and play objects they represent supportsthe conclusion that in match-to-sample situations, themore closely the symbol represents the object, theeasier the task of learning to associate the two- 64 -becomes (Keogh & Reichle, 1985; Sevcik & Romski, 1986;Romski, Sevcik, & Pare, 1988).PRII-RSOUISITS SKILLS Mary's successful acquisition of requestingbehaviours using an augmentative communication systemsupports the argument that the presence of strictcognitive pre-requisites such as a consistent yes/noresponse, understanding of object permanence, or theability to respond to verbal commands, are notindicators of the development of communicationabilities (Kangas & Lloyd, 1988; Rice & Kemper, 1984;and Romski & Sevcik, 1988). Mary's successstrengthens the need for further consideration ofinstructional strategies for use with severelydisabled children and validates the application ofaugmentative communication devices.GSMSRALIZATIOM Mary learned to generalize requesting behaviour- 65 -to a setting other than the instructional setting.She also used objects different from those used duringthe instructional sessions. Her successfulapplication of a previously learned behaviour supportsStokes & Baer's (1977) suggestion that the use ofdifferent materials and settings for reinforcing aresponse will facilitate generalization of the desiredbehaviour. Mary used the familiar combination ofcolour photographs and speech output to request playactivities . Factors identified by Calculator (1988)as being important to successful generalization of alearned behaviour which were present in this study,include the use of a highly transparent symbol system(colour photographs), consistent responses to Mary'scommunication attempts, and the use of highlymotivating, appropriate objects and activities (food,and play items) relevant to the learner's needs. Maryis a young child and play is the primary avenue ofexploration and learning for her. Generalization offood requesting to the play situation, will facilitatefurther development of social and communicationskills.^Mary was taught to use an augmentativecommunication device in the environment in which- 66 -she naturally participates in eating, and in play.This supports Calculator's (1988) conclusion thatgeneralization behaviour should be taught inappropriate environments.IPUTURII RIMS Eft NMIMary continues to use the Unicorn ExpandedKeyboard to request food choices during lunch-time.Her use of this device to select leisure activitieshas been expanded to include activities such as bikeriding and playing with a balloon. Instruction hasbeen carried out in a manner similar to that used inthis study. Overlays have been created to allow Maryto participate in group games such as Simon Says, andBingo. She is helped to "direct" her classmates bymaking selections on the Unicorn board. In thissituation, black and white drawing coloured withpencil crayons are used as the symbol system.In order for an augmentative communication systemto be functional for an active child like Mary, it- 67 -must be readily available for her use in a variety ofsettings, and during a range of activities. Relianceon the Apple HOS computer for operation of acommunication device limits the portability of thesystem, and is very expensive for provision in Mary'shome or Primary 2 classroom. Mary needs to haveaccess to a portable speech output device such as anALLTALK or a TOUCH TALKER. A portable device chosenfor Mary must allow for expanding symbol vocabulary,offer flexibility with regard to programming, andallow for the provision of several levels or overlaysfor use in a range of situations. It must be portableand durable. A funding source for this equipment willneed to be solicited. A referral to the CommunicationDisorders department at Sunny Hill Hospital is beingconsidered in order for Mary to have the opportunityto access the possibilities for a suitablecommunication system.In order to support Mary's use of photographs tomake requests at school, a visit to Mary's home wasmade by the author and Mary's speech pathologist.After a discussion with Mary's parents about the- 68 -results of the study, they expressed an interest inusing the photograph system with Mary at home.Mary's father took photographs of Mary's favouritehome activities.^These were the swimming pool, hertricycle, the television, preparing for a ride in thefamily car, and story time with her two youngersiblings. Grooming activities such as teeth brushing,toileting, and dressing were also represented byphotographs. These photographs were attached withclear contact paper to the walls and/or locationswhere they occur, and Mary's parents were instructedto give verbal and physical prompts appropriatelyprior to initiating the activities. They were alsoasked to consistently reinforce unprompted requestsmade by Mary whenever possible.In anticipation of the acquisition of a newsystem for Mary, the introduction of smaller symbolson the Unicorn Keyboard is scheduled to begin.Instead of a 4" X 4" square, Mary's photos will bereduced in size to 2" X 2". In order to furtherreduce this size, Mary will need to develop herability to point to, rather than simply touch thesymbols.-69 -mug! DIUCT/0110 Egg RBOBARCH Mary's family has begun to use her photographcommunication system at home. It will be appropriatefor the author to monitor Mary's ability to generalizeher skills to a different setting. The skill ofrequesting a drink at home using the same symbol Maryuses at school will demonstrate stimulusgeneralization as described by Odle et al.(1982).In order to provide further evidence supportingthe abilities of children with severe developmentaldisabilities to benefit from augmentativecommunication, additional case studies such as thismust be completed and published. Case studiescontribute to the development of further researchhypotheses, and provide opportunities for in-depthdiscussion and reporting of the subject andprocedures. Educators and researchers involved withchildren with multiple disabilities can be motivatedto apply new instructional strategies.- 70 -Additional research topics can include theinvestigation of appropriate instructional techniquesto promote generalization, the role of speech outputin the development of both receptive and expressivecommunication abilities in disabled learners, theeffect of facilitator training on the development ofcommunication skills, and the effective evaluation ofcommunication competence in augmentative communicationusers. Mirenda & Iacono (1990) believe that educatorsface a "communication imperative" for the 1990's.Persons with severe disabilities must have access tofunctional communication training.Recently, in British Columbia, the Ministry ofEducation established the Special Education Technology- British Columbia (SET-BC) initiative, whose role isto provide necessary educational technology to non-speaking students in the province. Assessment,training, and provision of technology, includingmicrocomputers, software, and electronic communicationdevices is provided along with the related servicessuch as seating/positioning, speech therapy,psychological assessment, medical consultation, andeducational planning.- 71 -This case study examined the ability of a multi-disabled child to learn to use a Unicorn ExpandedKeyboard in combination with photographic symbols torequest food.The initial application of augmentativecommunication technology has been with individuals whopossess normal or near normal cognitive functioning.These augmentative communication devices have improvedthe abilities of persons with disabilities such ascerebral palsy, multiple sclerosis, and/or spinal cordinjury to function as productive, contributing membersof an economic community. 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