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Occupational Therapy and Speech-Generating Devices

by Morgan Kurtz, MS, OTR/L


So many of the children we as occupational therapists (OTs) work with have special communication needs. At a very young age, children are what we consider to be “multimodal communicators.” Oftentimes, they use a combination of low and high-tech communication methods, such as sounds, pictures, signs, tablets, and many more. Typically, as OTs, communication is not our area of expertise—we lean on speech-language pathologists (SLPs) for that domain. However, OTs do play a critical role in the communication process.

In order to be a multimodal communicator, you need to incorporate motor components while communicating. How could a person use sign language, point to a core board or pictures, or select an item on a tablet that generates speech without basic motor skills? In order to practice multimodal communication, they will need to be able to isolate each finger, visually scan for what icon they need, create a motor memory pattern, and be able to create sentences. In between the pictures shown below, I have included a few bullet points of information to consider when looking into these types of devices!

This is an example of a low-tech communication board. When the student needs to take a break or use the bathroom, he pulls the icon off the velcro and hands it to the OT. This is where the beginning of understanding back-and-forth communication starts.

  • Did they have the hand/finger strength to pull the icon off the velcro?
  • Would they be able to visually scan for the icon they needed?
  • Visually, did they need words, icons, or both?
  • How large or small could the icons be for the student to be able to see them?

From velcro boards to touch-screen communication devices

This student is just beginning the augmentative and alternative communication (AAC) device process which is why minimal buttons are visible on the screen. The rest of the buttons are “hidden” for now and can be made visible when the student has enough knowledge of the device to expand her vocabulary. This is a student with hemiplegia so there are more things to consider when to comes to finger isolation and carrying the device.

  • Would the student be able to strong enough to carry around an AAC device with them all day? Would they need a strap or could they carry it in their hand? For instance, the QuickTalker Communication Device has a handle for easy carrying.
  • Did they have the finger isolation to be able to click one button?
  • Did they have the motor control to be able to move their finger toward a desired button and not hit any other buttons in the way?
  • Did they have the motor control to click the button once and not several times?
  • Would they be able to visually scan for the button they needed?

The student who uses this device is very fluent in his AAC device. So much so that he can pull up the keyboard when he cannot find a word and type in what he is trying to say. However, this student has a visual impairment. This was taken into account when placing icons on the page. Notice the color difference for core nouns, verbs, actions, and groups. Also, make sure to note the size of the icons is much larger than the last AAC device shown.

Here is an example of a student's AAC device who does not have a visual impairment. Take note that the icons are much smaller than the previous device as well as more grey-toned. This device has key items in a different color but is not sorted by the colored icons.

  • If the screen changes between selecting words, would the student have the visual memory skills to be able to reorient themselves with the new page and find the next button? (This could be specific to which program is being used, not all programs change all the words on the page when a button is pushed.)
  • Visually, where would the core words need to be placed? Would they be in the same location on each page?
  • Visually, did they need words, icons, or both?
  • How large or small could the icons be for the student to be able to see them?
  • How many icons could be on the screen without it being too distracting for the student?

In my experience, communication starts in its simplest form to ensure the child understands the back-and-forth nature of each communication method. If they sign for more food, they can understand how they are going to get more and if they point to the picture of a snack, they will get a snack. These items were something the multidisciplinary team in my school always worked on together. In our team meetings, the SLP would identify what they were trying to implement and we could carry it over into our sessions. We worked on everything from fading prompts to hand-over-hand to verbal cues, to independently asking for items that were related to our OT sessions.

Using augmentative and alternative communication devices

Once it is evident that the child has mastered a no-tech (sign) or low-tech (picture exchange board) system, they might become a candidate for a high-tech speech-generating device tablet. In the case of one such patient, I relied on the SLPs to let us know what was going to happen or what we should be trying to implement. However, when I got an email from the assistive technology representative at my school asking for my input on augmentative and alternative communication devices for a student, I was taken off guard, unsure as to why I was involved in the process.

Augmentative and alternative—why was I, an OT, involved? Wasn’t it the SLPs job to decide which device would be best for the student’s communication needs? Boy, was I wrong.

At first, I was asked to fill out a form identifying the types of items the student was working on in OT, how he was communicating, and how the device would be used throughout the sessions. I identified the strengths and weaknesses the child had for fine motor components in his educational setting.

Soon after sending this email, I received one back asking to speak at the meeting about the number of icons on a page and the size of the icons. That was it. Instantly I was unsure how to answer these two simple questions. I was a new graduate OT who had barely any experience with AAC devices, especially not when it came to a student’s ability to use one!

After I calmed down, I realized that the icon number on the screen and the icon size were nothing compared to all of the skills that the students who use AAC devices need in order to efficiently and effectively use a speech-generating device to communicate their needs to those around them. After observing a few trial sessions to probe for icon size and quantity of icons on the screen, I quickly identified many other areas that OTs need to address in order to properly help the SLP and team to recommend a quality AAC device for a student.

Sure, the SLP made suggestions on what programs to use, how to set up core vocabulary, and which words needed to be included or hidden. As the OT, I served a much larger role than expected. After working with the student to evaluate for icon size and number, I compiled a list of items that I also could report on that would be important to the AAC process.

One of the most important aspects for OTs and AAC devices are the words you chose to put on them! In the beginning, the SLP will do most of the training with the student but once it has been cleared to use with the whole team, highly motivating words are used. This progression is used to encourage the child’s use of the device; I mean, I would rather use it to request snacks than to request shoe tying, wouldn’t you? However, make sure to include an OT folder or section, include materials that are often used, such as markers or scissors, and make sure to include activities like coloring and cutting. It is always good to include sensory items too! Make sure to include items on their sensory diets that they can request throughout the day and during the OT session. AAC devices are very much so a multidisciplinary piece of equipment for a student and it takes the entire team to make sure the child generalizes the skills to be able to use their device in all environments.

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