Episode 306: Heidi Rabe: Supporting Switch Use for Clients with Complex Physical Needs

This week, Rachel interviews Heidi Rabe, an SLP who specializes in supporting AAC users with complex bodies who use switches and scanning to communicate! Heidi shares a wealth of information about scanning and switches, including how to evaluate if a student needs a switch, working with PT/OT to find the right switch spot, using partner-assisted scanning, and more!

Before the interview, Chris and Rachel discuss a question from a listener about a student who is “adding random words” (and how the least dangerous assumption is that it’s purposeful and meaningful, and we should get to the bottom of it)!

Key ideas this week:

🔑 When Heidi is considering scanning and switches for a client, she thinks about whether they can reliably select from the size array that they need in order to communicate. Also, are their motor skills reliable? Are they having difficulty selecting symbols, even with a keyguard or touch guide?

🔑 Partner-Assisted Scanning is a scanning strategy where a partner verbally offers choices at a consistent rate, and the AAC user indicates what word they want. PAS allows for scanning without the time constraints that exist when presenting choices on a speech-generating device. There is usually a book that tells the partner what choices to say, and in what order. That way, the partners are consistent every time, which allows the AAC user to anticipate what words are coming. See a video on it here.

🔑 When you are using auditory scanning on a speech-generating device, you want the preview voice to be very different from the speaker voice.  Otherwise, communication partners get confused and respond to the wrong voice. Also, ideally you also want the preview voice to be quieter, and to be transmitted through a personal speaker.

🔑 When doing Partner-Assisted Scanning, Heidi gives the option of “None of those” as the last option. Similarly, after they make a selection, you can offer “I have more to say” “That’s all I have to say” and “Oops, that was a mistake” as choices.

Transcript of the Episode

Please Note: This transcript was generated using speech recognition & AI tools; it may contain some grammatical and/or spelling errors.

00:00:08
Welcome to talking with Tech. My name is Chris Bugaj, and I'm here with Rachel Madel. Rachel, what you got for us this week?

00:00:13
Chris? We have a listener question that we're going to answer.

00:00:15
I feel like this is a really good question. And ironically, right before I hopped on, one of my slps on my team asked me this question, basically. So I was like, this feels of like I'm killing two birds with 1 st here. So this question comes from Margaret. She says, my student is very tech savvy and knows how to add words to his AAC device.

00:00:35
However, he gets stuck in this behavior of scrolling through his pages and adding random words. Any suggestions to decrease this behavior?

00:00:44
Yes. So let's start. Since your therapist just asked questions, said they have a similar situation, what did you suggest?

00:00:53
Well, there's a few things that I want to kind of highlight here with this question. So this idea of adding random words, I guess the question becomes, are they random? Right?

00:01:09
Yeah.

00:01:10
The least dangerous assumption is they're not random. Now, I have worked with students who are adding the same button over and over again, so it's kind of like anytime we have this peculiar behavior, I feel like the best approach is to get really curious. And we already mentioned the least dangerous assumption, but to really just assume that it's purposeful and meaningful and we need to get to the bottom of what's going on here. I feel like that's the least dangerous assumption is to really believe that this is not random. There's some type of intention here.

00:01:48
Now let's dive into what that intention could be. When I hear that he's super tech savvy and knows how to add words to his AAC device, I'm like, yes, that's awesome. Like, woohoo. We have a student who can add words, who has literacy skills. Great.

00:02:06
My first question would be, what's happening in this classroom for this student? He's tech savvy, he has literacy. Is he being challenged enough? Have we worked on literacy with him? How can we expand what he's doing?

00:02:19
How can we take this act of typing in words into his AAC, look at the words that he's typing, and then create literacy opportunities around those words so that he can have the ability to learn how to expand and grow and write? Basically, because it sounds like he has this kind of skill of adding words and gets really excited. How can we take it outside of the AAC and create opportunities for him to learn how to write using those words? Could be he likes the image. So how can we create some type of story with images or pictures or symbols or whatever, taking basically the elements of what the student's doing and then trying to create another learning opportunity around it?

00:03:04
Again, least dangerous assumption is that it's purposeful to him. And so we need to teach him how he can be purposeful to others and have a shared meaning with other people. Sort of just saying, hey, we don't understand why you're doing this.

00:03:19
Right?

00:03:20
Could you share it in a different way? And I know that sounds really simplistic, but always lean on the idea of educating. So, least dangerous assumption, then we're going to educate you about a different way. You could do that and that could be through here. Clearly sharing stories and sharing words.

00:03:37
He sounds like he's reading, so we could even have some reading component about. Here's where I add words, and if I add words in this place, then it might be confusing. I might not remember. But if I add it here, then it makes more sense and you can have a whole story that you write about this. And if you're not sure how to write that story, generative AI is your friend Chris.

00:03:57
I was literally just going to say we just did an episode on Microsoft reading coach and I feel like what an awesome opportunity to start building out literacy and writing for this student and have the text to speech because it seems like that's a component of this. He really likes, he likes to add something into a button and then probably touch that button and hit the button and listen to the word. So that's something that text to speech can do. He likes the image maybe of the symbol. He likes going through and scanning through.

00:04:28
What image is he going to select? How again, can we create opportunities outside of the AAC to show him other ways to do these types of activities?

00:04:40
Absolutely. So we mentioned creating stories and reading stories about instead of doing it here, do it here, right? Instead of using this tool to get that auditory feedback and type it out and have an image, do it here because it can share it with others. And then, like you said, expand that into other writing opportunities. And the other thing that leaps out to me is making a short video about that as well.

00:05:03
So from a universal design for learning approach, think about what are the different multiple modalities I could use to represent this concept that I'm trying to teach him? So I can make stories in one way and I can make stories in another way. I can make stories with slides in book creator or Google Slides or PowerPoint. I can use generative AI to help me come up with those stories. Sorry, not.

00:05:26
Or, and I could make a little short video of, here's why you want to do that, and here's how you do that and share in these multiple formats.

00:05:36
One other thing I'll add, because sometimes students are adding the same word over and over again. So I've had students who just love a word and they just keep adding it, and it does become tricky because all of a sudden you go to their home screen and it's like all of these other words, and now it's scrolling, and it can be problematic creating, again, learning experiences around. We already have that word. Let's search to see if we have the word. We already have it.

00:06:07
We don't need to add it again. We can write about it, we can talk about it, but we don't need to add it again. So, like, really teaching students around the fact that you can search before you add a word, you can search. I'm also just, while we're on the topic, a really big fan of adding some type of button or phrase that says, it's not in here. Like, I need this word because so often our students who don't have literacy skills yet are kind of scrolling and they're stuck.

00:06:37
They have an idea, but they can't find the word or it's not in there, and then they don't have any way to express that, and they usually have to find a word that's kind of similar, and then it becomes this kind of detective game. So having that and teaching students as part of that process to say, it's not in here, I need to add a word. Right. That communication can be really powerful for students, especially if they don't have the literacy skills yet.

00:07:06
Yeah, that can be really modeled by the communication partner. When you do the thing, when you're like, I'm not sure where that word is. And before I, again, do it like a think aloud. All right, I'm going to go search for it. Oh, it's not in here.

00:07:20
So you then show how you would say that on the communication device and then flip over the keyboard and start typing it out.

00:07:27
Yes, exactly. And I have done that with some of my clients, and they get really good at being like, it's not in here. And then it's like they're saying that all day, and I'm like, why are.

00:07:37
All these words not in there?

00:07:39
Like, hey, we need to add these things. And then again, it transitions very nicely into a literacy opportunity as well for students who, again, are not literate yet. It's not in here. Let's talk about what letter it starts with. It starts with the letter P that says.

00:07:58
And we're, like, going through that whole learning process as we're helping students learn.

00:08:02
How to add buttons.

00:08:04
And so kind of circling full picture back to this question. I'm really excited. This is such a great skill that this student has, and so I feel like celebrating, you know, Margaret, you have the opportunity to kind of reframe this for the team because I'm sure everyone's coming to you. Like, he's just adding random words and he just keeps adding buttons. And it's just, look at this home screen.

00:08:26
It's crazy. And it's like, we have the opportunity to respond to that and say, I'm so happy to hear that he is adding new words. That's a great skill that many of my students using AAC don't even have that skill yet. We have the opportunity to reframe some of these things with the teams that we're on, and then, of course, figuring out ways to kind of solve these problems and move forward in a way that makes sense. But I feel like our reaction to when people come to us and say, like so and so is doing this or is not doing this, that reaction can make all the difference in the world.

00:09:04
Absolutely. It sets the tone and the mindset.

00:09:07
And can really change someone's mindset through.

00:09:10
The words that we use. All right, Rachel, sounds like this student accesses the device. Well, we don't know. She didn't really explain how he accesses it. I'm sort of making an assumption that it's through direct select, but it might not be.

00:09:21
It might be through eyegaze, it might be through using switches. It would be great if we talked to somebody about alternative access modalities. Do you got anybody for us?

00:09:31
You know what, Chris? It's perfect because I had the pleasure of interviewing Heidi Rabe all about alternative access. Heidi is a fantastic clinician and has a specific specialty and expertise, I'd say, in alternative access. And it's an area of our practice where many slps feel daunted and overwhelmed. Even our AAC slps are like, oh, alternative access.

00:09:57
I'm not exactly know. It doesn't come up all the time in our work. And so I'm really excited that I had Heidi on. This has been a long time coming, coordinating.

00:10:07
When I was going to have Heidi.

00:10:08
On the podcast, she finally came on, and I had the pleasure of interviewing her. So I'm super excited to share my interview with Heidi Rabe.

00:10:28
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00:10:50
We'd so very much appreciate it. Now let's get back into the episode.

00:11:03
Welcome to talking with tech. I'm your host, Rachel Maidel, joined today by Heidi Rabe. Heidi, I'm so excited to have you here.

00:11:09
Thanks. I'm excited to be here.

00:11:11
This has been a long time in the making, so I'm super excited to dive in. First, just tell our listeners a little.

00:11:16
Bit about who you are.

00:11:18
So, like I said, my name is Heidi Rabe. I have been a speech path for over 20 years. I try not to think about that.

00:11:26
Sounds like a long time.

00:11:28
It is a long time, yes. Let's go with a long time. And I have always worked with clients, children and adults with developmental disabilities and complex bodies. So I specialized during my CF and never looked back, basically. And I now also have branched out to working with kids who are verbal, especially on literacy, and just higher level receptive expressive skills because the underlying therapy skills are the same.

00:11:59
So I've kind of taken the opposite path of a lot of people.

00:12:03
Yeah, I was going to say it's really rare to hear, like, I dove into AAC at the beginning of my career. I feel like it's usually was, you know, doing more general speech therapy. And then I got interested and passionate about AAC and kind of sought that out. But you had exactly the kind of.

00:12:20
Opposite trajectory I did.

00:12:22
I was really lucky that my grad program had a class in AAC, which, yeah, it didn't happen in the late 90s. Unfortunately, it's still not 100%, but that was not a thing in the late ninety s, and I took the class and I fell in love with it. My grad program also allowed you to specialize in neuromotor disabilities and neuromotive speech. Yeah, cognitive neuro.

00:12:51
Yeah.

00:12:52
Which also it doesn't do anymore. But I took all of the classes on neuromotor speech for kids and just got really interested in the neuro piece of things.

00:13:05
And then my practicum was with clients.

00:13:08
In a special ed school that were AAC users. So it just kind of feels like it was a very natural progression for me.

00:13:17
Yeah. So part of the reason I wanted to have you. Come on, Heidi. I mean, you're a very accomplished presenter and have really shared a lot of the work that you're doing. We talked about alternative access, and I know that that's an area that you have a lot of experience in, specifically with scanning.

00:13:35
And it's definitely an area of our field where I think a lot of clinicians feel very daunted and overwhelmed.

00:13:42
And it's.

00:13:43
It's something where I think as a field, we really need to understand a little bit better. Even myself as a clinician, when I was first starting with AAC, I was like, I'll do AAC, but not if it's like a kid that doesn't have direct selection abilities. Only because I was like, I don't feel like I'm qualified to start trialing, and I don't know even where to begin.

00:14:06
And then, of course, I figured out.

00:14:07
What I didn't know and how to find out the information that I didn't know. But even myself, I was so nervous with kids that weren't using direct selection and alternative access just felt so daunting. So I guess let's just dive in and talk about that. Let's start with just what are some of the signs that students do need alternative access?

00:14:29
So that's a really good question. I look at it in terms of.

00:14:35
Can they reliably select from an array size that they need to be able to communicate?

00:14:46
Is their motor reliable? So can they touch the symbols on.

00:14:51
A paper or on a device, or.

00:14:54
Are they having difficulty even when they have a key guard or a touch guide with them? So if they're still having that difficulty, then I start looking at alternate access. A lot of my clients are in wheelchairs and have cp or rare genetic conditions, so it's a little bit more obvious, but I do think it's an underutilized access method.

00:15:19
Absolutely. I love how you said the word reliably because I feel like that's such a huge piece. And there's a lot of subjectivity when it comes to this idea of reliably, but ultimately, it does have to be reliable. And I've worked with so many students or done consults, and I'm like, this isn't reliable as far as their fine motor being able to access with touch or direct selection. And so I love that you kind of specified this idea of reliable.

00:15:49
Thanks. Yeah, it is so important.

00:15:51
Yeah. The other thing I wanted to touch.

00:15:54
On is this idea of that you.

00:15:57
Mentioned of kind of robust vocabulary. I think a lot of times what happens is when students are using direct selection, they can only do it with super large icons, which inadvertently limits access to large robust vocabularies. So can you speak to that a little bit? Because I think that's an area where it's like, yes, they can direct select with three buttons on a screen, but.

00:16:25
Then we're using that and we're ultimately not allowing for or giving access to robust vocabulary.

00:16:33
Right?

00:16:34
Yeah, and we're not thinking about the.

00:16:35
Motor load because if you have three, four buttons on the screen, in order.

00:16:41
To have a lot of vocabulary, you.

00:16:43
Need to have a lot of touches.

00:16:45
Of the screen, which is a huge motor, executive functioning and cognitive load. So when clients can only access that, that is when I think about scanning and really think about parallel pathways. So it may be a partner assisted scanning that we're using and teaching the system that we think they're going to be eventually. And if you have a formal partner assisted scanning book, then you can access and teach them the pathways, do one hard thing and give them access to robust vocabulary while they're learning the motor skills. So even if they're not, if you think they may be a direct selector eventually and are working on refining those motor skills, it's not an either or, it can be an.

00:17:29
And that's a really good point for those of our listeners who are like, what is she talking about when she says partner assisted scanning?

00:17:37
Can you just define that?

00:17:39
Absolutely. So in partner assisted scanning, the partner is basically functioning like the communication device. So they are offering the choices at a consistent rate. And that is one of the main types of scanning. So you are offering the choices.

00:17:56
Usually there's a book to tell you you can do on the fly. When you're doing that, it's very important that you preview the options and then present them in exactly the same way with pauses and you're reading then the client's body language, or if you have an actual accept reject, like a yes no response, they're saying yes no, you're moving on to the next choice. So you can use that to teach the concept of scanning too, and give them more vocabulary. So really, like I said, the partner is acting like the device and offering the choices.

00:18:33
And even for my students who are using alternative access, particularly eye tracking, partner assisted scanning is a really good skill to teach kids because as you know, when we're using eye tracking, it's very fatiguing. So by the end of the day, after students have sat in school all day in front of their devices, they might not have the energy to communicate with their eye tracking system. And so having the ability to use partner assisted scanning, it just opens up a lot more communication opportunities for students. So that's something that I definitely recommend for all of my alt access students, I feel like should have some type of foundational partner assisted scanning so that when either the device isn't available or they're really tired, we have some type.

00:19:21
Of alternative way for communication to happen.

00:19:25
Absolutely. And even just in general, it can be as simple, I guess, teachers saying.

00:19:31
Hey, do you want to art, math, or science first?

00:19:36
Do you want to do art?

00:19:37
And then, look, math, science.

00:19:41
Yeah.

00:19:41
All mean, it can be something really formal, and it should be for, especially for all access systems. But I think it's an underutilized method in general of choice making and just our interaction with AAC users.

00:19:55
And that's a really good example of how you can offer choices. The reason that the visual is super important is because you want the order to be in the same way every time. And so I've worked with teams, and they're like, well, he has really severe vision impairment, so he's not even looking. I'm like, it's not even for him. It's for the communication partners.

00:20:15
Because when you have to anticipate as a AAC user using scanning, you have to know what to anticipate. And the more you hear the same options in the same way, you're able to then anticipate. And so as that example, having a paper based board that has those subjects on it so that the teacher can remember to kind of present it in the same way every time, it's just a really useful kind of addition.

00:20:46
Yeah. And in my sessions, I write it down whenever, if I'm presenting the options that we have for the day, I write the choices down so that it doesn't tax my auditory memory. And then I give them the same way.

00:20:58
Exactly. I know. I have a bad memory as well.

00:21:01
Yeah.

00:21:03
Okay, so kind of going back to the scanning, we're talking about this idea.

00:21:10
Of setting up students with these kind of alternative systems. Sometimes students are using things like pod books, which are very robust, and other times we can use it as kind of an adjunct to another system, maybe a high tech system that they're using.

00:21:26
Let's talk a little bit about the.

00:21:28
Affirmative response, because that's a huge part of scanning. And how can you find that reliably if you're working with a student that has a very complex body? How do we figure out what the yes response is.

00:21:44
That's an excellent question. I give preference to and try to get a conventional yes no. So if they have head movement, Gail Porter is big and Linda Burkhard are big on having single message devices, a tiny one at their cheek and one at your chin, so that you can teach those motor movements. Many of my clients, unfortunately, aren't able to do those motor movements or do them all the time, and we can't distinguish which ones. So if you can't do a conventional yes no, then I work with OTPT.

00:22:21
To decide what body part is most.

00:22:26
Do they have the most control over, and then often I'll put a single message device near that body part for yes. And I start with yes.

00:22:36
If that doesn't work, then I will.

00:22:40
Also just read their body cues. Some of our clients, when I've started out really early on with partner assisted scanning, like one at a time, then they may reach for the thing that they want and show no response for the thing they don't want. They may lean forward, they may smile.

00:23:00
There might be a breathing change and.

00:23:03
Giving them very specific feedback of, oh, I saw you do this.

00:23:07
I think it means yes, go with.

00:23:10
The thing, and then again watch their responses. So if there's a negative response, then you can work to repair that communication breakdown and try it again.

00:23:22
Yeah. And I love how you mentioned some examples of something as subtle as a breathing change, because we have to get really granular when we're thinking about how our students are responding, because sometimes even the slightest of motor movements is really challenging.

00:23:40
And so it can take a long.

00:23:43
Time sometimes to get to know a student and to practice and to kind of see. I love the fact that you mentioned this multidisciplinary team. These cases are the ones where you want to be reaching out to your PT and OT and kind of get all hands on deck just to make sure that we are really looking at the full picture as far as the motor, figure out what would be a good thing to practice, because I've worked with PTS or I've worked solo and then realized I was practicing with their not dominant side and all of these things. And so I learned my lessons the hard way. Okay, just reach out and make that extra effort to collaborate with the team to get as much information up front as possible.

00:24:30
And then it makes the trialing process a lot easier.

00:24:35
It does. And then also thinking about with that affirmative shaping, that and eventually that becoming a switch spot for switch scanning on.

00:24:44
A communication device in an SGD.

00:24:47
And I love how seamlessly that transitions. So we can start with something that's a little bit less robust and a little bit more foundational in nature, and then always be thinking about how can we transition eventually to something that is more high tech and more robust ultimately.

00:25:06
Right. And we also can start with robust. Just to be clear, there is no concrete starting point. Some clients need that starting small and building, especially as their motor skills build.

00:25:21
And some clients, if you have a.

00:25:23
Good switch site or two switch sites, you can start pretty robust from the start.

00:25:30
That's a really good point. Heidi, can you talk about this idea of two switches? Because I know that's another area of potential confusion for.

00:25:41
So we talked a little bit about partner assisted scanning. So usually when accessing a communication device, which is switches, you either have one or two switches, and there's different types of scanning patterns.

00:25:54
So there's automatic, which usually is done.

00:25:57
With one switch where the device is presenting the choices at a consistent pace. And then when the person hears it.

00:26:06
They touch the switch to say which one they want. So they may hear stop, go, hello.

00:26:14
They think, oh, yeah, that's the one I want.

00:26:16
And then they touch hello. The device says, hello.

00:26:21
Or with one switch, you can also have what's called, sometimes called an inverse, sometimes called a hold scan, where they hold the switch down until they hear the one they want and then release. The challenge with single switch scanning is timing. The device is always controlling the timing. I will admit I have a preference, if possible, physically, to do two switch scanning, even though it does take more of a motor, has more of a motor load, and you need more motor control. The client is always in charge of the scan pattern, in charge of the scan rate.

00:27:01
So usually you're doing what's called step scanning. So you have a mover and a chooser. Your mover is moving along your choices, so more stop. So they're hitting the switch every single time to move the choices along so they can stop and think if they need to. If they're distracted to want to say something else, then they can come back to the message, which happens a lot with my clients, but they're in control of the pace.

00:27:27
And then when they hear the one.

00:27:29
They want, they select it or choose it with the chooser or select second switch.

00:27:34
And that can be done either in a linear pattern, which is one by one, which I generally get away from as soon as possible, because again, the motor load and go into what's called a group pattern. So the word that you're hearing is representing a group of other words, and.

00:27:55
So that's where you're kind of scanning through. I guess they wouldn't be columns, but rows.

00:28:01
It could be rows. It could be groups. So you can scan through rows or you can have groups. So some devices have, like, a quarter of a page. Like, core scanner has eight by PRC.

00:28:13
Cell, Tillo has eight kind of. They call them blocks.

00:28:17
Eight blocks on that. Really, technically, it's eight blocks in a row, so nine on a page.

00:28:24
Or.

00:28:24
You can do it as columns. So there are a lot of different options once you get into a group. The concept is just that the first word, that audio queue, represents something else.

00:28:38
When you're starting off. I obviously know there's, like, a lot of different moving pieces and seeing how a student responds, but are there any strategies that you've learned kind of off the bat to be more successful? Because there's a lot of moving pieces with trying to optimize this type of an approach.

00:28:55
Yeah.

00:28:56
So, really, parallel pathways are parallel programming.

00:28:59
So we talked about having both the partner assisted scanning and the motor, the communication device, or having just practice in scanning with low cognitive effort while you're learning. So that whole concept of do one hard thing. The hard thing is either the motor or the language, not both. So separate the two out at the beginning stages.

00:29:25
Can we dive into that a little bit more?

00:29:27
Because I totally hear you.

00:29:29
I feel like if we're asking students.

00:29:32
To practice language that they're not super familiar with yet, and on top of that, at a motor component, we're not.

00:29:39
Likely to be successful.

00:29:40
So, would your recommendation be kind of assessing, language wise, what is familiar or.

00:29:49
More practiced, at least receptively, and then using language? And maybe there's, like, a concrete versus abstract nature meaning. Are you using more nouns that are more concrete and maybe easier to use language wise? Tell me a little bit more about.

00:30:06
Your thought process there.

00:30:07
So, honestly, I generally start with pragmatic functions and make sure all the pragmatic functions are there from the beginning, because that's the start of robust language. So there do tend to be nouns, but I do a lot of actions and a lot of social commenting and protesting and rejecting in sessions, so I tend to take more of a pragmatic approach than a grammar class approach.

00:30:36
Okay, got it.

00:30:38
And are you focusing on one specific phrase or word or what does that look like?

00:30:46
So, very early on, I tend to.

00:30:50
Model or demonstrate for using it myself.

00:30:54
And then doing a lot of mapping.

00:30:57
Or what some in the field call responsive or responsive language input. So I'm seeing their body looking really happy I'm going through and using the.

00:31:07
System myself to comment on what I.

00:31:11
Think their body is saying. So they're using behavioral, non symbolic means.

00:31:17
I'm mapping that language onto the situation.

00:31:21
With the symbolic means, so I'm using it entirely myself. And looking, kind of going back to your question, like talking about affirmative responses, looking for a sign that they have something to say, and then I'll comment, oh, it looks like you have something to say, and I will start the scanning. Okay. Or if they're using learning their SGD, then giving them time to play, and it's a lot of errorless, just attributing.

00:31:48
Meaning to what they're saying.

00:31:49
Exactly.

00:31:50
Got it.

00:31:50
Okay.

00:31:51
Yeah. But I tend to be more of a kind of top down language teacher than bottom up. So I want all of those functions as much as we can from the start. If that's overwhelming for families, then I'll narrow it down.

00:32:09
But we don't know what someone else.

00:32:12
Wants to say and can't predict what.

00:32:15
Type of communicator they're going to be.

00:32:17
Really? And a lot of my kids, as soon as I add social vocabulary in, they start flying with it. My clients are sassy, and I love it and I embrace it. It's an ongoing joke in my practice.

00:32:32
But we have sassy clients.

00:32:34
Yeah, I mean, exactly.

00:32:36
And I think that if we're thinking.

00:32:38
Through the pragmatic functions, especially if we're working with students who are socially motivated.

00:32:44
Then we're really covering all our bases.

00:32:46
As far as making sure that we.

00:32:47
Have the different kind of branches pragmatically covered.

00:32:53
Exactly.

00:32:54
So that they can protest, they can.

00:32:56
Say something is wrong, which are honestly.

00:33:00
The most common things that a lot of my clients start with. Or they can say, go to have things go again. That's how my clients, anyway, have gotten the power of language.

00:33:14
Yeah. And finding things that are super motivating, obviously, is key. And engagement.

00:33:19
Exactly.

00:33:21
Right.

00:33:22
Okay.

00:33:23
So just kind of circling back to this idea of language.

00:33:29
So you're doing a lot of aided language input for the different pragmatic functions.

00:33:33
Or branches, and then once you start.

00:33:37
To see kind of an affirmative response, then you're kind of narrowing in and targeting that specific thing based off of what the student has then showed you. And then you're kind of practicing that.

00:33:49
Language with the motor aspect or.

00:33:54
Yeah, once they get to the motor. So oftentimes I'm providing the language input and stimulation with the partner assisted scanning. So, like at the start, like I said, they were separating the two, and then they may be playing switch games on an iPad, for example, or maybe making a switch toe go. So depending on where they're at in their understanding of understanding of switches and that progression.

00:34:21
Okay, go ahead.

00:34:25
Once they understand the function of switches and that different switches can control different things, that's where I start jumping into learning two switch scanning and play.

00:34:41
So what I'm hearing you say is.

00:34:43
Focusing on the motor practice, which.

00:34:48
I think it's so misunderstood that these motor practices are so important. And if we just jump to language.

00:34:57
We haven't practiced the motor.

00:34:59
And so playing games and things like that that are really engaging and motivating for students is a really great way to practice the motor.

00:35:06
Yes, exactly. I have also been taught that motor looking at what is kind of the bottleneck. And for many of my clients, especially those using scanning, motor is most often the biggest bottleneck. So working on that separately in play, because we learn better through play and then language as well. So again, it's all that parallel pathways.

00:35:30
And focusing on things that are engaging and motivating. Like play.

00:35:33
Exactly. I play all day.

00:35:36
I love it. That's what we should all be saying as pediatric slps, right?

00:35:41
Exactly.

00:35:42
Okay, awesome. So I'm trying to think of where.

00:35:47
I want to go next. I feel like there's so many questions, and I feel like we are just kind of skimming the surface here. But I'm trying to. We are ask questions to get the information for people who are just, like, beginning and trying to understand how they can start using this and being successful with this. I guess one question that comes to mind is.

00:36:08
Where do you think most.

00:36:09
Clinicians kind of get stuck? Or what is one area where you're.

00:36:14
Like, maybe you come in and do.

00:36:16
A consult with another team, and you're like, oh, here's like an aha thing.

00:36:21
That I can teach.

00:36:23
I think part of it is expecting.

00:36:25
Language production too soon and not separating out the motor and the language piece, not being consistent.

00:36:35
These things can take a lot of time, so we see subtle results and.

00:36:41
Big results over time.

00:36:44
But it takes.

00:36:46
A long time to get that motor control. And I think it's also hard for newer clinicians or people who aren't as familiar with scanning to know what to look for in an SGDC device that.

00:37:03
You shouldn't just put the access method.

00:37:07
To scanning on one that's developed for touch because the language that you need is going to be later. So really looking at and learning how to look for devices that are optimized for scanning, there's this thing called the dynamic triangle, that you want the most important vocabulary first. So if you're starting to develop even a partner assisted scanning, you want the most commonly used vocab first because you want to lessen the motor load.

00:37:41
And is that specific to the student.

00:37:44
Or that's just generally speaking, like, high.

00:37:47
Frequency core language that you would start with most students.

00:37:53
Do you mean in terms of what to prioritize?

00:37:55
Yeah.

00:37:56
So what to prioritize? I mean, I do generally prioritize core, but there are things student specific, and I do find that kids with physical disabilities, a lot of mine, are medically complex as well. So the something is wrong. I need help.

00:38:11
Those tend to get bumped up for.

00:38:15
My clients, especially in the partner assisted.

00:38:19
Setups, because that's what they need to.

00:38:22
Be able to communicate often, because, unfortunately.

00:38:26
They have a lot of pain.

00:38:27
Yeah, absolutely.

00:38:30
And I feel like that self advocacy piece is so important, and it's oftentimes.

00:38:34
What parents want the most is to.

00:38:36
Understand what's happening, because these kids are in and out of the hospital sometimes and have all types of kind of medical complications, too. And so being able to communicate about your body and what's happening inside of it and what you need and all of those things become really important.

00:38:52
Yeah.

00:38:52
And there are some systems that were rearranged. I don't know of any that are specifically developed for scanners, but unity has some that are rearranged for scanning. Different people in the field have different opinions on it, but there is a unity 84 range for scanning. Grid has some arrangements specifically for scanning. TD Dynabox has some specifically for scanning.

00:39:21
Wordpower has a couple specifically for scanners, too. So starting by looking for and thinking about, was this developed for a scanner and then customizing for your specific client or student?

00:39:34
That's a really good point, because I feel like what happens is we kind of start with a system, and we're trying to get direct selection sometimes, and then we're like, well, I guess we'll just try scanning, but we're doing it on the same system, or we're just changing the grid size a little bit. And so I like that recommendation of.

00:39:52
Trying to get really clear about systems.

00:39:55
That were set up with scanning in.

00:39:57
Mind because they are set up in a different way.

00:40:00
And I forgot to mention, core scanner obviously is intended for scanners. But I will say I have two clients using core scanner. I do like the system a lot, but the nouns are really hard to get to, so I've moved them into the second block to make it easier.

00:40:19
Because they're really amazing at descriptive teaching or descriptive language, but I've actually had to teach nouns for almost the first.

00:40:30
Time in my career.

00:40:33
Yeah, well, sometimes kids are very clear and specific about the specific thing that they want, and so it does become important.

00:40:40
It's not all core.

00:40:41
I mean, we know the core, but.

00:40:43
It'S also nouns, too.

00:40:45
Exactly. But one of my clients has is like, go up fast to talk about an airplane. Because airplane methodically is harder to get to.

00:40:56
Absolutely.

00:40:57
And go and up and fast are all easier to get to. And they're more automatic words, which I love. It's a great descriptive teaching. I also want them to say airplane.

00:41:08
Yes, exactly.

00:41:09
And also with a communication partner like.

00:41:12
You who understands descriptive teaching, you can kind of put that puzzle together. Someone else is going to be like, what? Not understanding this idea of three core.

00:41:22
Words actually representing airplane.

00:41:25
Exactly.

00:41:27
Yeah.

00:41:29
As long as we're avoiding that. Sorry, go ahead.

00:41:31
No, go ahead.

00:41:33
So, as long as we're mindful of the vocabulary and just how we're teaching, it's really with scanning has taught me how much the language system and the organization of the language system influences the.

00:41:53
Words that clients use.

00:41:57
As I'm saying this, of course, it's obvious, and there's a whole social science discipline researching this. I know I've seen Ted talks on how just language in general influences how.

00:42:08
We think and the words we use.

00:42:10
Because those are the words we have. But in AAC in general and scanning, specifically, the words that they have easier access to become the words that are more frequent.

00:42:25
So really thinking about how that's going to impact down the road, this is.

00:42:33
Kind of like blowing my mind, if I'm being honest. It is so intuitive. But as I'm thinking through this.

00:42:43
I.

00:42:43
Don'T even know that it's super specific to just alternative access either.

00:42:48
Right.

00:42:49
I see this with students who are using direct selection. It's like, well, it's way easier for me to just say eat instead of to specify what I want to eat, even when the opportunity presents itself. So I'm just going to kind of go with what I know, or I'm just going to kind of go with what was taught first. Right. So it does make it really important for us clinicians to really think strategically about the words we are introducing and the order in which we're introducing them.

00:43:15
So that we can really kind of.

00:43:17
Get the most bang for our buck, knowing these are the words that are going to be used more often and more frequently.

00:43:25
So, yeah, this is like, again, that's.

00:43:28
Blowing my mind a little bit.

00:43:30
Yeah.

00:43:31
These are the deep thoughts I have about AAC.

00:43:34
This is what Heidi thinks about before she goes to bed at night.

00:43:37
Exactly.

00:43:39
Oh, no.

00:43:40
But it's so true.

00:43:41
And it's just like, I think we're kind of. Oh, like, we'll just kind of get started. And I think vocabulary selection, I mean, that could be a whole nother podcast. I get questions. Just today I got a question from a clinician who's like, I just got.

00:43:54
A kid started on a lamp.

00:43:55
What do you think I should start with as far as vocabulary? And I'm like, how am I supposed to answer that? I'm like, okay, I have 25 questions about the kid. It's so complex, and there's so many different factors to consider, but it is.

00:44:09
So important when we know, with all.

00:44:12
Kids who are AC users, how long it could take to learn one word or phrase, and then to think about the alternative access users who have such.

00:44:23
Challenges at times with motor and the.

00:44:26
Timing and all the things.

00:44:31
It could.

00:44:31
Be even more hours. They need to actually learn a word. So we need to be really strategic about the words that we're selecting and teaching.

00:44:40
Yes.

00:44:40
And that's teaching them what we teaching.

00:44:45
Them what we think is important, too. So being mindful of our own biases put in there.

00:44:53
Totally.

00:44:54
It's like another great point of we don't actually know what kids want to say, and it's our best guess at the language that we model based on the reactions that we're kind of gleaning from them, but being really cognizant, because I've definitely been in teams where I'm just like, why are we teaching this? Is this what this kid really wants to say? It's just like, really always thinking through the lens of what does this student actually want to communicate? And being cognizant of our own biases, I feel like, is really important.

00:45:29
Yeah.

00:45:30
And reminding ourselves that one of the.

00:45:33
Goals is autonomy, being able to say what you want to say to who you want to say, how you want.

00:45:38
To say it, when you want to say, really?

00:45:42
I know Asha says snug, but to.

00:45:44
Me, autonomy is really the goal.

00:45:46
Absolutely.

00:45:47
And I think that it can feel a little tricky to teach autonomous communication when students have such complex bodies.

00:46:01
Is there a way that, especially for.

00:46:03
A student who's using partner assisted scanning. Let's talk about that for a second, because we oftentimes think of independent as synonymous with autonomous, and it's really not right. With partner assistant scanning, you're not necessarily independent because you need a partner, but you can absolutely be autonomous. So can you kind of talk about that distinction and some things to think about?

00:46:28
Yeah, absolutely.

00:46:30
And it is a really important topic because, like you said, autonomous and independent. And I'm going to throw in their authentic, since that's the name of my practice, are not. And part of why I chose that name of my practice of authentic expression is that it's still coming from the person.

00:46:46
So language has a constraint of a.

00:46:50
Set number of words. We have a set number of words in our vocabulary. So whether you're using an AAC system or whether you're using partner assisted scanning, those are the words that are being.

00:47:01
Presented to you, and you can still select.

00:47:06
So you're still using a yes, no.

00:47:08
Response or accept reject in partner assisted.

00:47:12
Scanning to express your message, but your body may not be able to access the switches, or you may be in the pool, you may not be in your wheelchair for whatever reason, or just having a high tone, tough day that the partner is still offering the choices and you're still accepting, rejecting.

00:47:32
So the partner is functioning like the communication device would.

00:47:39
And that kind of circling back to why it's so important to have actual written out partner assisted scanning and being consistent, because then that's their language system, or one of their language systems. It's still coming from them. We're just doing the job of the device.

00:47:59
One other thing that we haven't mentioned that I feel like is super important to kind of that point is always having an option of at the end or something else, right? So if we give options, we have to always be cognizant to include or something else not here, right? Because it could be we give four choices and it's like, no, none of those, right?

00:48:20
None of those. Yes. And that's a really great point. We need to give the option of none of those. I usually give it as the last one, and then after they make a selection, I will often continue it with, I have more to say.

00:48:36
That's all I have to say. Or, oops, that was a mistake. So giving that option also of, hey, that wasn't the one I wanted. And I always put more to say to begin with because I want to be kind of not subliminally, but subtly encouraging the person to have more to say. Like, I have the expectation you have more to say where when you start with, that's all I have to say.

00:49:03
Even if they're at the one word level, that is sending them the message.

00:49:07
That you should be done.

00:49:09
I love that distinction. And it is very subtle, but you're so right. Circling back to what words we teach first. And the easier the words are to access, the more likely we're going to hear those words. I mean, it's the same thing.

00:49:22
If it's easy to say I'm all done, then, yeah, it's kind of like when we're at the gym, it's like, yeah, I'm all done. These crunches. I'm done. Versus if it's not option until later, we're like, okay, I'll keep going.

00:49:38
I've got.

00:49:38
So that distinction is really powerful.

00:49:42
Yeah. And it's sending them the message that.

00:49:45
We'Re here for you.

00:49:47
We're creating this space. We want to hear what you have to say.

00:49:51
Keep going.

00:49:52
Absolutely.

00:49:54
This has been so great. Heidi, is there anything else, any other gems of wisdom or strategies that we haven't covered that you think are relevant to alternative access or specific to scanning?

00:50:07
The things we haven't covered is scanning on an iPad.

00:50:11
That scanning on an iPad. Just because this iPad has it doesn't mean it's going to work well.

00:50:20
Real honest. Absolutely.

00:50:23
I've experienced that firsthand.

00:50:25
Yes. And some of the apps require you to have inapp scanning, which then, at least historically, my interface isn't playing well with my iPad. To test it out right now, too, then if you're trying to have the native scanning, you have to switch back and forth a lot. So I tend to use the iPad for scanning for games, and if we want scanning, then I tend to use a dedicated device.

00:50:52
Yeah.

00:50:54
When we're thinking about students that need.

00:50:57
Alternative access, it's just like long term. These systems were designed for alternative access, and it is amazing that we now have those options on an iPad and.

00:51:10
That technology continues to improve, which is really exciting. But ultimately, when we're thinking about long term success for our ace users who.

00:51:19
Are alt access users, then absolutely, I would agree with getting a dedicated device and you have then all the support and all the help that you need and all the just. It's a lot.

00:51:32
Yes.

00:51:32
Yeah.

00:51:33
You're not dependent or things aren't changing.

00:51:37
And being messed up.

00:51:38
If you have an iOS update that.

00:51:40
Has little glitches in it.

00:51:43
Totally.

00:51:43
Which you're losing.

00:51:44
Your iOS updates are so annoying to me.

00:51:49
Yes, they are.

00:51:51
You have lots of iPads.

00:51:52
I'm like, oh, gosh.

00:51:54
Okay, let's go.

00:51:56
Yes. The other thing we didn't really talk about is that some people can use just straight up visual scanning, so not having auditory cues and what we've talked about is all auditory scanning. So most of my clients need auditory. They benefit from the visual, but they're all auditory learners. And when you're doing that on a communication device, it's important to have one voice, the preview voice being very different from the speaking voice and ideally quieter and going through a personal speaker because partners get very confused and respond to.

00:52:31
The preview voice if they're similar volume.

00:52:34
What? Another great hack there. That's really smart, having two different voices for those. Yeah. Makes a ton of sense for just streamlining communication with a communication partner, especially one who's not as familiar with AAC.

00:52:48
Exactly.

00:52:49
Then you know which voice is talking.

00:52:51
I love it.

00:52:53
Okay.

00:52:54
These are all really great. I'm so happy that you came on and shared all your wisdom. Is there anything else that you can think of?

00:53:03
Those are kind of the big things for me.

00:53:05
There's so much to kind of dive into here. I'm so excited that we had an entire episode dedicated to alternative access and specific to scanning. I feel like it's an area, like I said in the beginning, that can feel very overwhelming and daunting. I guess my last question, Heidi, is.

00:53:22
That even after all of our listeners.

00:53:25
Who feel daunted, listen to this. Where do they start? What's a good place to kind of just dip your toe in the water to get started with alternative access specific to scanning?

00:53:36
I mean, in terms of teaching a client or learning, just, I would say.

00:53:40
Just starting with that client on their caseload who they've been like, I don't know what to do with this kid. What can they now go and start.

00:53:48
Doing with that case?

00:53:50
I would say using a single message.

00:53:54
Device or a switch and keep it working with your OTPT, finding a spot for it. Keep it there for at least a month, take data on it and see how it goes, and then if you.

00:54:05
Need to move it.

00:54:06
Perfect.

00:54:07
So, yeah, really refining that affirmative response and getting that motor practice for the switch, I think, makes a lot of sense. And there's a lot that you can do with just that within your sessions. And that's really the practice to kind of really get started and then we.

00:54:25
Can expand from there.

00:54:27
Exactly.

00:54:28
Yeah.

00:54:28
I'm a really big believer in getting good at one thing and then kind of expanding, because otherwise you just feel like there's so many things to do and I don't know where to start. It's like, just get really good at one thing, and that feels like a.

00:54:41
Really good thing to get good at.

00:54:43
Exactly.

00:54:44
And one hard thing at a time. For us and for our clients and students.

00:54:48
Totally amazing. Heidi, thank you so much for coming on and sharing all of your wisdom. I'm so excited to share this episode and just really appreciate you coming on, making the time, and sharing all that you've learned over the years.

00:55:01
Thank you. I'm happy to talk about scanning anytime.

00:55:05
I love it. I'm sure we can have you on. We can dive even deeper. I feel like I've learned so much, too. So thank you again for coming on.

00:55:13
I'm really excited to share this episode.

00:55:16
Thanks so much for having me.

00:55:18
For talking with tech, I'm Rachel Madel, joined by Heidi Rabe. Thank you guys so much for listening, and we'll talk to you next week.