Background

Communication is a fundamental right, but as the BILD Communication factsheet states, communication difficulties affect anywhere between 50% and 90% of people with learning disabilities. This factsheet also suggests that about 20% of people with learning disabilities may have no verbal communication skills but that they do demonstrate a will to communicate, and show an expectation of getting a response.

In recent year, the literature has begun to reflect the interest in augmentative and alternative communication systems as a way of improving communication abilities, There has been little published though that explores in particular, the use of speech generating devices for people with learning disabilities.

Method

The researchers in this case study were interested to look at the impact on the communication skills and opportunities available to an individual of the use of an augmentative communication aid, in particular, a dynamic display speech generation device, or SGD. An SGD is used by a person to produce a previously recorded or digitised spoken message.

The researchers set out their findings from a therapeutic case study of a woman in her 40s, who is described as having a moderate learning disability, attention hyperactivity deficit and who is non-verbal.

The researchers point out in their background information that the woman has a recent history of expressing herself through behaviour that which has included the destruction of property and physical aggression. Recently she had been receiving support from staff in her service who were trained in and using a positive behaviour support model known as Multi-Element Behavioural Support.  One of the insights that emerged for the support team from the functional analysis was that a key function of this behaviour was a ‘desire to interact with others.’

What they did was to develop a communication profile, which identified the woman’s communication strategies and also identified a number of specific challenges. They identified immediately that her comprehension abilities were significantly better than her expressive skills.

They used two methods to gather data at two points. They used semi-structured interviews with staff in both the residential and day service, and observation and analysis of a ‘communication dyad’ or two way conversation piece between Ann and one other, both before the intervention to get a baseline, and the after the intervention to
evaluate the outcome.
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The outcome of the analysis of the first interviews and communication dyad gave the researchers insight into the way in which the SGD might be used in the woman’s day to day life

The researchers thought that a key element associated with the intervention would be training and support for staff to introduce the SGD in the woman’s life, to support her to use it and to be champions of a sort in the service for ensuring that the device was used.

To that end, they selected one key member of staff from both residential and day service and these staff attended training in the use of the device which also included background to understanding Total Communication and support for strategies to create opportunities to use the device,

Findings

They interviewed the staff following the intervention and staff suggested that the device had offered the woman a voice and that verbal expression had been increased as a result.

One important impact noted by staff was that the use of the device enabled the woman to have conversations beyond the here and now and offered a tool to repair conversation breakdown

The analysis of the communication dyad post intervention also suggested some gains, for example increases in the percentage of intervals during which the woman took conversational turns, maintained topic of conversation and was able to introduce new topics of conversation

There was also a reduction in the frequency of communication breakdown shown in the dyad analysis, which would seem to confirm staff impressions.

Conclusion and comment

The authors point out in their introduction to this paper that the evidence base for the use of augmentative communication for adults with learning disabilities when considering speech generating devices is currently not extensive. Often when considering interventions, we must consider the best current evidence and it may well be that at this stage, the amalgamation of case studies may be the best that we have at our disposal.

This study showed some significant gains for this woman in terms of the way staff viewed her communication abilities and from the analysis of recorded dyads.

There are of course some concerns about the study, for example the inherent difficulties of therapists involved in introducing and delivering a therapeutic input evaluating said input. This is not a comment on the integrity of the therapists involved in this study, but a legitimate concern about a potential for unconscious positive bias in analysing results. This is tempered in this study by the introduction of the dyad analysis as a way of cross referencing staff reports. It was not clear to me from the paper however what the time frame was for the post intervention interviews and analyses and it might be interesting to revisit the situation at some point in the future to see whether the gains have been maintained and indeed, whether further gains have been made.

It was also interesting to me to reflect on the motivation of the person concerned, which seemed quite high and the fact that this communication intervention followed a good clear functional analysis and was introduced into the context of a service that was working with positive behavioural support. These may well be factors that were supportive of the successful outcome in this case. I was also struck by the care and attention that was required to deliver the intervention, particularly the identification of and support to key staff members to ensure that opportunities to use the device were identified and explored. This active support for the intervention may also be a key factor.

This case study however adds to the evidence offering confidence to people considering the use of SGD’s for people with learning disabilities, but perhaps also warns of the need to ensure the setting conditions are conducive to success.

It’s good to talk: developing the communication skills of an adult with an intellectual disability through augmentative and alternative communication, Hagan L & Thompson H, in British Journal of Learning Disabilities, 42, 68–75

BILD Communication Factsheet, Jones, J 2002