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Complex Communication Needs

Appraisal for speech pathologists who support people with disability

Complex Communication Needs Core Standard Appraisal, October 2015 2

BACKGROUND

This appraisal was developed for speech pathologists in Family and Community Services (FACS) by the Practice Leader Speech Pathology in Clinical Innovation and Governance. External agencies and services working with people with disability may also find it useful.

This appraisal supports FACS speech pathologists to translate their knowledge regarding complex communication needs into their everyday practice. It forms part of the supporting resource material for the Complex Communication Needs Core Standard program. Before undertaking the appraisal the program participant may wish to read the aligned resource material:

1. Complex Communication Needs (CCN) Practice Guide for Speech Pathologists who Support People with a Disability, and;

2. Frequently Asked Questions for the Core Standards Program.

The Core-Standards Program and associated resource materials can be found at http://www.adhc.nsw.gov.au/sp/delivering_disability_services/core_standards.

It is inevitable that with such a large and skilled workforce some FACS practitioners will already have the required knowledge. To obtain a certificate in a core standard program a participant can choose to omit further learning. They can simply complete the appraisal and demonstrate the professional application.

GUIDELINES

The program participant must identify a suitable work practice support person who is willing to complete this appraisal. This is ideally a speech pathology senior clinician/supervisor with appropriate skills and experience. An alternative support person may be identified if there is no appropriate professional supervisor, or if the current supervisor believes another person may be better suited to appraising the participant’s knowledge.

The participant is required to arrange a time with this work practice support person to plan and administer the appraisal. The appraisal is self paced and participants are simply asked to answer questions in professional supervision when they feel ready to do so.

http://www.adhc.nsw.gov.au/sp/delivering_disability_services/core_standards


This appraisal consists of the following three sections:

1) Theory

• The information under each question is intended to provide the key points each participant should address. The information is directly from the associated practice guide. It provides participants with a summary of expected knowledge, and guides the support person in the appraisal of this knowledge. Participants can provide more than is itemised and should provide supportive literature to back up their answers if needed.

• Questions may be answered verbally or in writing.

• Questions may be answered in the context of a group discussion as long as the support person is present and satisfied with the participant’s response.

• The support person will sign off each question when they are satisfied the required information has been presented.

2) Discussion (regarding application to work practice)

• Case discussion / examples must have been completed within the previous 12 months.

• Case discussion / examples are acceptable if completed in collaboration with another practitioner as long as the support person can identify the participant’s level of contribution and is satisfied that the requirements are met.

3) Direct observation

• With the consent of the person with disability and / or their person responsible, the support person must observe the participant demonstrating the requirements.

• A direct observation of an assessment session and a direct observation on an intervention session are required.

• There is not a scoring system in this appraisal. All questions are to be answered to a satisfactory level, and there must be satisfactory demonstration of application to the practitioner’s work in the areas outlined.


DISCLAIMER

This Complex Communication Needs Appraisal was developed by the Practice Leader in Speech Pathology within the Department of Family and Community Services, New South Wales, Australia (FACS).

This appraisal has been developed to indicate whether a participant has increased their knowledge through the completion of the Complex Communication Needs Core Standards program. It has been designed to promote consistent and efficient good practice. It forms part of the supporting resource material for the core standard program developed by FACS.

Access to this document by practitioners working outside of FACS has been provided in the interests of sharing resources. Reproduction of this document is subject to copyright and permission. Please refer to the disclaimer in the Complex Communication Needs (CCN) Practice Guide.

Whilst the information contained in this appraisal has been compiled and presented with all due care, FACS gives no assurance or warranty nor makes any representation as to the accuracy or completeness or legitimacy of its content. FACS does not accept any liability to any person for the information (or the use of such information) which is provided in this appraisal or incorporated into it by reference. FACS does not intend nor guarantee the use of the appraisal as assessing a level of competence by practitioners working outside of FACS.


COMPLEX COMMUNICATION NEEDS APPRAISAL

PARTICIPANT NAME: __________________________________

SUPPORT PERSON NAME: _____________________________

SUPPORT PERSON POSITION: __________________________

DATE APPRAISAL COMMENCED: _______________________

THEORY QUESTION

Support Person Comments

Meets requirements (Y/N, date, initial)

1) What are complex communication needs?

Complex communication needs (CCN) is a term used in the literature to describe people who have little or no speech, where there are many possible causes.

People with complex communication needs may have communication problems associated with a wide range of physical, sensory, cognitive and environmental causes which restrict/limit their ability to participate independently in society (Balandin, 2002).

Within the context of the ICF it relates to people who have a severe limitation in communication functioning, related to their health condition, body structures and functions, activities and participation, environmental factors and personal factors.


THEORY QUESTION



2) Who has complex communication needs?

People with complex communication needs are a diverse group. In addition to a speech impairment they may also have a combination of physical, vision, hearing, sensory processing or cognitive impairment/s.

Some primary diagnoses include:

Developmental- developmental delay, intellectual disability, cerebral palsy, autism, genetic / congenital syndromes, epilepsy, mental health / psychiatric conditions, such as selective mutism and psychosis

Acquired- progressive neurological conditions, muscular dystrophy, motor neuron disease, multiple sclerosis, Parkinson’s disease, Huntingdon’s disease, Alzheimer’s disease / dementia., cerebrovascular accidents (CVA) / strokes, resulting in dysarthria, dyspraxia and / or aphasia and traumatic brain injury.

(Perry et al, 2004).

3) Identify and describe three potential impacts of having complex communication needs for the individual and their communication partners. (Participant should be able to name and describe at least three of the impacts below).

• Social: experience loneliness, isolation, limited friendship circles. Interactions might mostly be with immediate family and paid carers.

• Psychosocial: includes motivation, attitude, confidence, and resilience (Light & McNaughton 2014). How a person perceives her or himself impacts on how they interact with those around them. Constant difficulties in communicating can be highly frustrating and may result in


THEORY QUESTION



behaviours of concern. Alternatively, some people respond by becoming increasingly passive and stop making active attempts to communicate.

• Education: Many students with CCN have difficulty accessing their education if not provided with the right support to develop effective communication skills. Some students with CCN have significant challenges in learning to communicate and may develop behaviours of concern. Other students may have difficulties learning to read and write.

• Employment: for many people with CCN, participating in the paid workforce requires a lot of motivation, skill and determination, as there are attitudes, communication and physical barriers that make this difficult. There is a variety of barriers to obtaining and maintaining employment: skill limitations, lack of education and job preparation, attitudinal barriers, architectural barriers, transportation barriers, technology limitations, and communication breakdowns (McNaughton et al, 2002).

• Mental health: Mental health conditions, including depression and anxiety, can co-occur with CCN and related disabilities. People with CCN will vary in their capacity to identify their needs for assistance related to mental health and their capacity to participate in discussions or counseling about this.

• Criminal Justice System: People with intellectual disability are estimated to be over represented within the prison population. Their disabilities may not always be fully recognised, nor their needs for communication support understood. People with CCN are vulnerable to being victims of crime, including crimes perpetrated by people who live or work with them.


THEORY QUESTION



4) Describe why a person with complex communication needs might engage in behaviours of concern.

Behaviours of concern can occur for a variety of reasons. They are generally acknowledged to be communicative in nature.

They may occur because a person:

• has not understood what people are saying

• wants an item or an activity

• wants attention

• is expressing feelings about something

• doesn’t want to do something

• doesn’t like an activity

• finds the demands of an activity too difficult

• wants an activity to stop

• has a medical condition / could be in pain

• has sensory processing difficulties.

(Clinical Innovation and Governance 2014b; Dossetor, White & Whatson 2011).

They could also be a behavioural indicator of a mental health condition (Hansson 2011).


THEORY QUESTION



5) Explain the speech pathologists role in supporting people with behaviours of concern.

An experienced speech pathologist may be a member of a multidisciplinary team implementing positive behaviour support. The speech pathologist will play an important role in assessing the person’s communication skills and developing communication supports.

The speech pathologist should determine if the person with behaviours of concern has an Incident, Prevention and Response Plan or Behaviour Support Plan. These should be read before meeting the person for the first time.

The speech pathologist should be familiar with their organisation’s behaviour support policies and procedures. They should also have an understanding of restricted practices as well as the policies and procedures related to use of these practices.

6) Explain how the International Classification of Functioning Disability and Health (ICF) can provide an overarching framework for your assessment.

• It encourages speech pathologists to see the whole person and consider their communication needs within the context of other related factors (Walsh 2011).

• It links communication to broader life skills.

• It highlights the interactions between health conditions, body functions and structures, activities and participation as well as acknowledging the influence of environmental and personal factors (Threats & Worrall 2004).

• Communication disability impacts the individual and the people they communicate with.


THEORY QUESTION



Looking at a person’s communication within the context of environment and communication partners provides a coherent way to improve functional outcomes.

• Encourages intervention goals to be functional and relevant.

7) How can a speech pathologist adopt a person centred approach to their assessment and intervention?

• Support the person with disability and their family/ carers to actively participate in their own planning and decision-making.

• Provide training and support about the process of decision making (if required).

• Make information accessible to people with disability and their families/ carers to enable them to know about possible options related to decisions they are making.

• Provide strategies to support the person with disability to express their ideas, priorities and preferences.

• The rights of the person with disability

should always be put first. • Ensure informed consent is provided for

planning, assessment and intervention.

• When decisions are made by someone else, such as a parent/guardian or carer, it is important to ensure that the person with disability is involved and agrees with the decisions.

• Have an awareness of the Supported Decision Making Framework.


THEORY QUESTION



8) Outline two best practice principles and/ or approaches that should be applied to your assessment. (Participant should be able to name and describe at least two of the principles and/ or approaches below).

• Dynamic: Dynamic assessment provides the opportunity to find out the difference between the person’s ability unassisted and what they can do when given appropriate supports and scaffolds (Iacono & Caithness 2009). It focuses on discovering what the person can learn to do rather than measuring their performance (Law & Camilleri 2007).

• Participation Model: The Participation Model has guided AAC assessment for many years (Beukelman & Mirenda 2005). It helps to analyse the person’s environments, activities for participation, communication partners and personal factors that either assist communication or make communication difficult.

• Person centred: Assessment must involve the person with CCN. If the person appears to have very limited communication, and their level of understanding is unknown then the speech pathologist should assume that the person can understand what is being said to them and speak directly to them during conversations. For a person who is unable to participate in discussions directly, involve the person who knows them best. This might be their primary caregiver, parent and/or their guardian/advocate. Gather information about the person’s preferences, abilities and communication needs.

• Collaborative: It is important to understand what other team members are assessing and how the information they gather can inform the speech pathologists’ assessment and


THEORY QUESTION



intervention. It is also important for the speech pathologist to share information about the communication assessment process and findings with other team members.

• Culturally sensitive: If another language is spoken at home, assessments may require the assistance of an interpreter. The interpreter will need to be briefed about the situation if they have not had experience working with people who have complex needs. When working with people from Aboriginal and Torres Strait Islander (ATSI) backgrounds, it is important to find out about the families’ culture, their attitudes to disability and their experience in working with a speech pathologist. An ATSI disability support worker may be able to provide support in relation to communication and cultural knowledge and to help ensure that appropriate strategies are suggested.

9) Describe the difference between indirect and direct assessment methods. (Participant should be able to describe the two methods below).

Indirect- Gathering information by talking to family / communication partners to find out about the person’s background, diagnosis, medical history, professionals currently involved, what support they have received in the past in relation to their communication, what their life experiences have been, their current communication abilities, their current activities and interests and what outcome they are hoping for. It also includes reviewing their file and documentation for relevant information.

Direct- Involves the use of specific assessment tasks to identify the person’s communicative strengths and deficits. This may include the use of formal assessment tools and checklists. It also includes observing the person communicating with their usual communication partners, in their usual


THEORY QUESTION



environments. Thorough observation may take place over a number of sessions and environments. Observations can be both informal and formal using published assessments. They can also be face- to-face or video-recorded.

10) Explain why a formal assessment might not be appropriate for a person with complex communication needs

• Most formal assessment tools have not been validated for use with people with an intellectual disability.

• People with disability may have very different experiences to people the tests were designed for.

• People with disability may perform very differently in an isolated “test” situation compared to their daily environment (Downing 2009).

• Physical access to these assessments can be difficult for those who have a physical and / or sensory disability.

• May not provide meaningful information on what the person with disability can do i.e. their strengths.

• The amount of time taken to administer norm referenced test needs to be balanced against the information they are likely to provide.

11) List four assessment tools that are suitable to use with a person with complex communication needs.

For example:

• AAC Profile (Kovach 2009).

• Communication Matrix (Rowland 2012;


THEORY QUESTION



Rowland & Fried-Oken 2010).

• MOSAIC (Smidt 2010).

• Social Networks (Blackstone & Hunt Berg 2003, updated 2012).

• Triple C Checklist of Communication Competencies (Bloomberg et al. 2009).

12) Outline five principles that are recommended when developing intervention programs for people with complex communication needs (participant should be able to outline at least five of the principles below).

• Everyone communicates.

• Communication competence will require linguistic, operational, social and strategic competence, resilience and cultural competence.

• Materials should be age appropriate.

• Intervention should be carried out within natural settings as much as possible.

• Intervention will be a collaborative team effort.

• Intervention must be culturally appropriate.

• Intervention involves training communication partners.

• Intervention will involve using activity and task analysis.

• Intervention will involve adaptations to enable the person with complex communication needs to participate and achieve success.

• The environment should be set up in a way that


THEORY QUESTION



supports use of the person’s communication.

• Good instruction will use natural cues and sufficient scaffolding, so the person achieves success.

• Prompting hierarchies can assist use of communication strategies.

• Communication profiles / instructions about how a person communicates should be readily available.

• Communication equipment requires ongoing management and maintenance.

13) Identify two tools you might use to measure outcomes of intervention? (Participant should be able to identify at least two of the interventions below).

• SMART goals

• Goal Attainment Scaling (GAS)

• Australian Therapy Outcome Measures (AusTOMs)

• Canadian Occupational Performance Measure (COPM)

• Individually Prioritised Problem Assessment (IPPA).


THEORY QUESTION



14) Describe two examples of intervention that would be suitable for people with complex communication needs and are not AAC systems. For each example, suggest a situation where these interventions may apply. (Participant should be able to describe at least two of the interventions below).

Some examples are:

• Applied Behaviour Analysis (ABA)

• Developmental Social–Pragmatic Model

• DIR®/Floortime™ Model

• Ecological Approach / Participation Inventory

• Hanen Programs®

• Intensive Interaction

• Marte Meo

• Video Interaction Guidance.


DISCUSSION

Application to work practice. Sample required, must have been generated within the previous 12 months.



Discuss a case where the following was incorporated when working with a person with complex communication needs:

• Person with disability and their family/ carers actively participated in planning and decision making.

• Assessment/ intervention was person centred and evidence based.

• A combination of direct and indirect assessment methods were used to obtain information about the person’s communication skills.

• Analysis and interpretation of assessment findings.

• Assessment findings were discussed with the person with disability and their family/ carers to assist in selecting the most appropriate intervention.

• Identification of person centred goals.

• Intervention involved training communication partners.

• Use of outcome measures to monitor and review progress.

• The environment was set up in a way that supported use of the person’s communication.

(Review progress notes, reports and other written evidence).


DIRECT OBSERVATION

Observations must have been conducted within the previous 12 months. Observations are ideally in real time, but may also be done via filming



Observation of the speech pathologist interacting with a person with complex communication needs during an assessment session and an intervention session are required. Assessment

Is there evidence of the following practices being administered where possible/ relevant?

• Person with disability and their family/ carers actively participate in assessment.

• Assessment is person centred and evidence based.

• Assessment is holistic and functional.

• A combination of direct and indirect assessment methods are used.

• Assessment findings and recommendations are discussed with the person with disability and their family/ carers. Information is provided in an accessible format.

• The person with disability and their family/ carers are given the opportunity to ask questions about the assessment findings.

• The speech pathologist provides information about the future direction of intervention.

• The speech pathologist records and

documents the assessment.

Impressions, clinical reasoning and outcomes are discussed with the support person following the interaction.


DIRECT OBSERVATION

Observations must have been conducted within the previous 12 months. Observations are ideally in real time, but may also be done via filming



Intervention Is there evidence of the following practices being administered where possible/ relevant?

• Person centred, functional, meaningful goals are selected.

• Person with disability and their family/ carers actively participate in intervention.

• Intervention is person centred and evidence based.

• The intervention contains elements that are appropriate to the findings of the communication assessment.

• The intervention enhances the person’s ability to communicate

• The speech pathologist ensures the person

who will carry out the intervention understands what they have to do and how to do it.

• The speech pathologist records and

documents the intervention.

• The speech pathologist provides information about ongoing intervention, progress and review.

Impressions, clinical reasoning and outcomes are discussed with the support person following the interaction.


I, the SUPPORT PERSON, confirm that all requirements have been met for this core standard appraisal.

SIGNED: ___________________________________

NAME: ____________________________________

POSITION: _________________________________

DATE: _____________


References

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Beukelman, D. R., & Mirenda, P. (2005). Augmentative and Alternative Communication: Supporting Children and Adults with Complex Communication Needs (3rd ed.): Paul H. Brookes Pub.

Blackstone, S., & Hunt Berg, M. (2003, updated 2012). Social Networks: A

communication Inventory for Individuals with Complex Communication Needs and their Communication Partners. Verona, Wisconsin, USA: Attainment Company, Inc.

Bloomberg, K., West, D., Johnson, H., & Iacono, T. (2009). The Triple C:

Checklist of Communication Competencies. Assessment Manual and CD Rom (Revised edition ed.). Victoria: Scope Victoria.

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Law, J., & Camilleri, B. (2007). Dynamic assessment and its application to children with speech and language learning difficulties. Advances In Speech Language Pathology, 9(4), 271-272. doi:10.1080/14417040701516522

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