CHC08 Disability Behaviour Support Skill Set Learner Resource Suite Learner Workbook 2

Transcription

1 Learner Resource Suite Learner Workbook 2

2 Community Services and Health Industry Skills Council Ltd This resource is under license and copyright restrictions. Please refer to the licensing agreement for complete information. Published by Community Services and Health Industry Skills Council Ltd ABN PO Box 49 Strawberry Hills, NSW 2012 Telephone: (02) Fax: (02) Community Services and Health Industries Skills Council Ltd Page 1 of 76

3 Workbook 2: Communication Section 1: Communication... 3 Complex Communication Needs... 5 Augmentative and Alternative Communication... 7 Identifying Communication Needs The Participation Model Section 2: Communication Assessment Barriers to Communication People Who Can Assist with Identifying the Needs of a Client Communication with other stakeholders Section 3: Implementing AAC Strategy Prompting Environment Reinforcement Motivation Stimulation to Learn Monitoring Opportunities for Review Community Services and Health Industries Skills Council Ltd Page 2 of 76

4 Section 1: Communication The person who cannot talk Author unknown I am the person who cannot talk. You often pity me: I see it in your eyes. You wonder how much I am aware of... I see that as well. I am aware of much... whether you are happy or sad or fearful, patient or impatient, full of love and desire, or are just doing your duty by me. I marvel at your frustration, knowing mine to be far greater for I cannot express myself nor my needs as you do. You cannot conceive my isolation, so complete it is at times. I do not gift you with clever conversation, cute remarks to be laughed over and repeated, I do not give you answers to your everyday questions, responses over my wellbeing, sharing my needs, or comments about the world around me. I do not give you rewards as defined by the world's standards... great strides in developments that you can credit yourself; I do not give you understanding as you know it, What I give you is so much more valuable... I give you instead opportunities. Opportunities to discover the depth of your character, not mine; the depth of your love, your commitment, your patience, your abilities; the opportunity to explore your spirit more deeply than you imagined possible. I drive you further than you would ever go on your own, working harder, seeking answers to your many questions, creating questions with no answers. I am the person who cannot talk. ACTIVITY 1.1: Reflect on the above words. What impact does this poem have for you in your role? Community Services and Health Industries Skills Council Ltd Page 3 of 76

5 Communication is fundamental to all aspects of life and is the foundation for learning. The Australian Bureau of Statistics defines communication as understanding and being understood by others: strangers, family and friends. Communication allows us to enjoy social relationships where we share thoughts, problem solve, express emotions and feelings, learn, develop self image, give feedback and influence others. Language is essential to communicate. Humans are the only species to have developed an elaborate system of communication that uses words, gestures and sounds that all combine to form meaningful units of language. Communication refers to the process of transferring a message from a sender to a receiver using language. There are two aspects to communicating effectively; 1. Expressive language. Involves the ability to formulate words and sentences in the brain to communicate with others. 2. Receptive language. Refers to comprehension and the ability to understand what is being said and/or read. We communicate through our entire message our spoken or written words where 7% of the communication is made up of the message itself, and 93% of the communication is made up of the non-verbal aspects of the message such as touch, eyes, tone of voice, signs, vocalisations, behaviour, gestures, facial expressions or miming. I RECEIVE Community Services and Health Industries Skills Council Ltd Page 4 of 76

6 According to Speech Pathology Australia, all of those aspects of communication fit into five main areas: 1. Speech. The physical production of sounds. 2. Language. Understanding what words mean, putting sentences together, writing clearly, and understanding written language. 3. Pragmatics. The social conventions of how we interact with each other. 4. Fluency. The smooth rhythm and pattern of talking. 5. Voice. The production of sound by vibrating the vocal cords. i ACTIVITY 1.2: What do you think are the most important principles of effective communication? Complex Communication Needs People who have complex communication needs (CCN) are unable to communicate effectively using speech alone. They and their communication partners may benefit from using augmentative and alternative communication (AAC) methods, either temporarily or permanently. Many people with a disability have complex communication needs which cover a range of issues in the areas of speech, language, auditory and visual processing. CCN considers receptive language skills (difficulties understanding spoken language), expressive language skills (difficulties producing speech), or both. Some general characteristics of CCN are: The inability to follow instructions. Incomprehensible speech. Difficulty in identifying visual cues. Overly slow speech. Trouble with articulation, voice, and fluency. Stuttering. Difficulty in forming sentences (often saying words out of order). ACTIVITY 1.3: Give an example of a client you work with who has complex communication needs. Community Services and Health Industries Skills Council Ltd Page 5 of 76

7 How Many People in Australia Have a CNN? In 2003, the Australian Bureau of Statistics (ABS) reported that 20% of Australians were living with a disability. The definition used to identify people with a disability included anyone with a limitation, restriction or impairment, which has lasted, or is likely to last, for at least six months and restricts everyday activities. Additionally a further 21% of Australians were reported as living with a health condition that did not restrict their everyday activities. Reportedly, 86% of people identified as having a disability experienced limitations in selfcare, mobility, communication, or restrictions in schooling or employment, and 76% experienced more than one limitation and/or restriction with communication. People with severe or profound core activity limitations are at the most severe end of the disability spectrum. Specialist disability services have tended to target this group. The ABS does not regard communication disability independently, but rather, regards communication as a restriction that is secondary to another disability. A study by Perry, Reilly, Cotton, Bloomberg, and Johnson (2004) reported that 1 in 500 (0.2%) Victorians were living with a disability and had complex communication needs (CCN). Areas of severe or profound core activity restriction were identified in a survey conducted in 2009 by the Australian Institute of Health and Welfare. Of the 6.6% Australians who had severe or profound core restriction, 10% experienced this restriction in the area of communication. The majority of people with a disability have a physical disability. Generally people experience complex communication needs secondary to their physical disability. People with CCN can be of any age, of any culture and from any socio-economic background. A substantial proportion of care for people with multiple disabilities is provided by their family members and friends. Other statistics from the 2008 NATSISS of the most common types of disability or long-term health conditions for Aboriginal and Torres Strait Islander people include: More than 105,000 people have physical disabilities, such as paraplegia and quadriplegia. More than 79,000 people have disabilities or long-term conditions that restrict everyday activities or require treatment and medication, including Alzheimer's disease, dementia, arthritis and heart disease. More than 55,000 people have sensory disabilities, such as visual impairment and hearing impairment. More than 25,000 people have psychological disabilities, such as schizophrenia and depression. Community Services and Health Industries Skills Council Ltd Page 6 of 76

8 ACTIVITY 1.4: Discuss the impact of CCN on skill development and community participation. What does this mean for your role as a support worker? Augmentative and Alternative Communication Augmentative and alternative communication (AAC), is the term used for all communication that is not speech, but strategies which are used to enhance or to replace speech. AAC is used to increase the understanding of language, and to augment, supplement and enhance expression of language. For example, we can augment speech for a person who has a hearing impairment by using gestures, pointing, signing, spelling, writing and body language. It is a combination of two distinct terms: Augment means to add to or to enhance. For example, we can augment our speech for a person with a hearing impairment by using gestures, pointing and body language, the person with a speech impairment can augment expression by using gestures, pointing, VOCA or Makaton. Alternative means a choice or a substitute. We can use alternative communication to speech using symbols, signing or by spelling. Your clients may experience communication difficulties which include trouble speaking, understanding, reading or writing. Many people experience a communication disability as a result of brain damage suffered from a stroke or head injury, and people who have degenerative neurological conditions can exhibit the same communication difficulties. The two major communication difficulties your clients will display are: 1. Aphasia or dysphasia. This is a disorder which is the result of damage to the language centres of the brain and can affect a person s ability to talk, listen, read and write. 2. Dysarthria. This affects the muscles of the mouth, face and respiratory system making the muscles weak, move slowly or not at all, causing speech disorders. AAC can help clients who are unable to speak to be able to: Communicate Develop language skills. Reduce their frustration in conveying their message, meaning or feeling. Socialise. Have control over what happens to them. John, a person with a severe communication disability describes AAC To me, and others like me, AAC puts us in society. It lets us have a voice. For me, having a Liberator [voice output device] has changed my life completely. Community Services and Health Industries Skills Council Ltd Page 7 of 76

9 ACTIVITY 1.5: What are the general principles and practices of augmentative and alternative communication? Augmentative and Alternative Communication systems AAC systems are made up of a range of AAC aids, symbols, strategies, techniques or methods used to help a person who has a hearing, speech or visual impairment where the person has difficulties in receiving or expressing a message to others. AAC can be both aided and unaided. AAC systems are very diverse as they depend on the capabilities of the user. The AAC system you adopt with your clients may assist your client with hearing, comprehension or expression of verbal cues or spoken words. The system could be simple such as object symbols or written text, or more technologically advanced using computers or software packages. ACTIVITY 1.6: What AAC systems are used in your workplace? As a group, create a list of AAC systems and demonstrate the way they are used to support your clients. Community Services and Health Industries Skills Council Ltd Page 8 of 76

10 An AAC system can be a short- or long-term solution to assist with communication. When using an AAC system, it is necessary to assess the client s abilities and requirements ensuring they use the most appropriate AAC systems. Assessment via a family centred approach (parents, sisters, brothers, peers or friends) and observation of your client in a range of settings can offer valuable insights to understand the unique needs of your client. Using AAC systems will not delay or impair natural speech development, especially with children. It is natural to utilise the most accessible communication method available. Speech surpasses any other AAC system for speed and effectiveness. Research shows that AAC facilitates the development of spoken language by increasing interaction, language skills and improving functional verbal skills. Where AAC systems have been developed in support of an individual, careful analysis should be made of: 1. The portability of the AAC system itself. 2. The client s capacity to use the AAC system. 3. The competency or capacity of carers across environments to use the same AAC. AAC Strategies AAC strategies are utilising the AAC system in an effective way for the client. It includes the selection and use of a range of AAC systems to help develop a person s communication. It is vital you are familiar with a range of AAC devices to understand the strategies available to implement an effective system. ACTIVITY 1.7: Complete the table below. Which AAC systems are used in your workplace as a response to the assessed communication preferences and skills of your clients? Unaided Strategies Aided Strategies Community Services and Health Industries Skills Council Ltd Page 9 of 76

11 ACTIVITY 1.8: Research the case study of Helen Keller or Anne McDonald. How did AAC affect the way they were able to communicate? ACTIVITY 1.9: How can you ensure that augmentative and alternative communication strategies are correct for the person s level of communication? Communication Partners Communication refers not only to the communicative skills of the client, but also to those in the client s support system, particularly carers. For people with an intellectual disability and complex communication needs it is crucial that all parties are able to communicate appropriately and effectively. This will usually require the design and consistent implementation of a formal communication system. As a worker in the disability sector you are a communication partner with your client and should aim to understand how they perceive themselves and their world. Effective communication maximises participation and minimises limitations as it enables people to express their personality, humour, interests and dislikes. People with complex communication needs are more vulnerable as they are less able to communicate their fears and concerns. The way you observe and communicate with your client is one way to reduce the risk of abuse, assault or neglect. It is essential for successful everyday interactions with others. ACTIVITY 1.10: If your client has not had a recent communication assessment by a speech pathologist or therapist, and you observe that their behaviour may be linked to their frustration in not being able to communicate, what is the process you must follow in your workplace? Community Services and Health Industries Skills Council Ltd Page 10 of 76

12 Another part of your role as a support worker is to collaborate with the client s family to reach an agreement on the service expected. The client has a wide range of communication partners, it is important you work with others to identify the communication needs of the client. This will guide the development of the client s Individual Plan but should also promote engagement of the family as valued stakeholders in the process. Most of us communicate differently depending on the person, how comfortable we feel, the environment and the level of rapport, so remember this when working with your client s other communication partners. ACTIVITY 1.11: Create a mind map of the communication partners for one of your clients. Who do they communicate with? Family Parents, siblings, extended family Carers and friends Supportive relationships Others Health professionals, teachers, other agencies Community Services and Health Industries Skills Council Ltd Page 11 of 76

13 Identifying Communication Needs To identify the communication needs of a person with a disability it is important to use a person centred approach, where the focus is on the client, their needs, concerns and wants. This takes into account the client s choices, their family and culture, specific language and communication abilities, their socialising skills, their important relationships, and their learning strengths and weaknesses. The first step is to collect data to make an accurate assessment of a person s abilities and skills. This assessment uses a range of tools, instruments and diagnostic assessments. The focus is to emphasise the person s capabilities rather than their disabilities, impairments and problems. When a client first comes to a disability services organisation, a coordinator or intake officer will acquire their history. The information on the client s history is then used to create a client profile which includes information disability services workers need to effectively support the client. Further information can be requested if required. Workers are permitted to access the files of clients for whom they directly provide support, using and acquiring information a need-to-know basis. To ensure client history and client files remain precise and contain valuable content, all information recorded must be complete, accurate, objective and current. The language used must be respectful, non-judgmental and age appropriate. The date and the client s name Community Services and Health Industries Skills Council Ltd Page 12 of 76

14 must be included on all information, and the worker recording the information must clearly print their name and sign their entries. It is natural to unconsciously make assessments of your client s communication needs but having a standardised method of measuring their communication is a more objective and consistent way of monitoring their needs and improvements. You may be required to ask your client questions and observe them as they communicate. Using standardised records will make your comments more objective. This method will also show evidence of any changes and patterns in your client s communication behaviour. ACTIVITY 1.12: Who in your organisation is involved in identifying communication needs of clients? Communication skills will differ across client groups, and from individual to individual. For example, you may have a client who is verbal, but when they become excited they speak quickly and merge their words together. Simply asking this client to slow down and repeat what they said can be all it takes to achieve effective communication with them. You may have another client whose speech is very unclear and you are unable to understand them. If this person can read and write, you may ask them to write what they are trying to convey. Other clients may be completely non-verbal, and in this situation the client may have a variety of preferred communication methods. These alternative communication methods may be Makaton, simple gestures, and the client may also use communication books or chat books. Clients who have no method of communicating may become frustrated leadingthem to engage in behaviours of concern, as the only method communicate. Community Services and Health Industries Skills Council Ltd Page 13 of 76

15 ACTIVITY : How do you recognise the communication styles of individuals you are working with? Show me first by interacting with me as a person who you d normally interact with. If you treat me as a stupid person, I m not going to engage with you. Rodney, a 20-year-old with Down syndrome and severe hearing loss. Although these are skills you already have because of your experience in the industry, many people in the community tend to ignore people, or assume that they don t want to contribute. ACTIVITY 1.14: If Rodney was your client and his GP did not include him in discussions, but relied on you to interpret, how would you encourage the GP to engage with Rodney? ACTIVITY 1.15: Give an example of a client who has AAC needs and how you have adapted the way you communicate with them. Who have you sought assistance from? Community Services and Health Industries Skills Council Ltd Page 14 of 76

16 Generally, most of the information you have about your client will be gained from your own observations and questioning of the client. Like any relationship, it is the power of understanding that builds trust and gives the relationships direction. In conducting a less formal assessment, it is important that you consult closely with your client asking them questions while you observe how they communicate with you. You may need to use AAC strategies to assist you. Here are some guidelines which can assist you to communicate efficiently and successfully with a client who has a communication disability: Make sure you have the client s attention by using their name, gaining eye contact or respectfully touching their arm. Start your communication with the assumption that the client can understand you, and then adjust your level of communication based on how they respond. Ask the client how they want to communicate if they do not use speech. This could include offering them communication aids or devices, or finding a way to answer yes or no to questions using eye gaze or head or hand movements, sign language, gestures or facial expressions. If you cannot understand the client you may need to ask whoever is accompanying them for assistance. Make sure your language is appropriate for the client and the situation, using simple, clear words and short, uncomplicated sentences. Remember that if the client is an adult, don t speak to them as though they are a child. Use visual information such as pictures, diagrams, signs, object, gestures or miming to aid with understanding. Make sure you maintain a respectful tone and volume, and use a different way of providing information or asking a question if the client doesn t understand you. Remember that raising your voice won t help. Don t rush the communication, instead make sure you allow the client time to listen, process your words and then formulate a response. If you wait patiently this shows you are interested and respect what they have to say. To check that the client understands what you have said, ask them to rephrase it in their own words instead of simply asking Do you understand? as they may simply answer yes to avoid embarrassment, or because they think that is the answer you want. If you don t think the client has understood you, try repeating the information or question more slowly or using different words. It is your responsibility as a disability services worker to make sure your message is understood correctly. If you don t understand your client don t pretend to understand. Instead be honest and take responsibility for a communication breakdown, saying I m sorry, I don t understand what you re telling me. Would you please tell me again? If you can t understand or make yourself understood try a different approach, look for an alternative way to communicate. Request involvement from another worker or family member who is familiar with the client. You will also need to remember: Community Services and Health Industries Skills Council Ltd Page 15 of 76

17 CHC08 Disability Behaviour Support Skill Set A person with a communication disability may need help with daily living tasks such as self-care, and accessing and participating in the community. A client s personality, the presence of other disabilities and social support can play an important role in how your client functions in day-to-day life. If you re not sure whether your client can understand you, assume that they can, and check their understanding throughout the communication to adjust your language and communication style accordingly. Always show respect for your client, and communicate in a way which acknowledges the age of the person and the value of their contribution. ACTIVITY 1.16: What other communication methods have you found work with your clients? Establishing Effective Communication Behaviour Communication is a two way process. A client can resort to behaviours of concern if others do not respect the communication skills they already have or fail to develop existing skills. Difficulty with communication cannot only be the result of one person s difficulty with the process. It is easy to presume the client is the cause; however those supporting the person need to modify their communication skills to effectively interact with the person. This is best done by keeping your communication succinct, using key words nouns and verbs and supporting the client through the use of pictures, objects and practical demonstrations. Communication is more effective when you couple words with items, pictures, gestures, or give an example. An adaptive stance defined by Hobbs ii, emphasises the equality and interdependence of the people involved, as well as the need for mutual value and respect. This is opposed to the maladaptive or authoritarian stance when one person dominates or overprotects another person. Principles that foster adaptive two way communication include: Allow the person time to get their message across. Observe closely and listen carefully. Avoid jumping to conclusions and taking control. Assume nothing and gather your information directly from the communication. Minimise distractions that might interfere with the client s attempts to listen and observe. Help people use whatever is available in their environment to communicate by ensuring they have access to any communication tool, for example, a communication book or electronic communicator. Community Services and Health Industries Skills Council Ltd Page 16 of 76

18 Make use of a person s preferred communication strategies using their language or an interpreter, gestures, key words or pictures. Community Services and Health Industries Skills Council Ltd Page 17 of 76

19 The Participation Model CHC08 Disability Behaviour Support Skill Set AAC use is both short-term and long-term as is based on current requirement and projected future opportunities, needs and constraints. The participation model as defined in Augmentative and Alternative Communication: Supporting Children and Adults with Complex Needs (Beukelman & Mirenda 2005) provides an organised, consistent and systematic way to undertake assessments related to AAC strategies. We will use the model throughout this work book. The participation model works across three phases: 1. Today. Assessing the communication needs and identifying barriers to the participation. 2. Tomorrow. Planning and implementing of AAC strategies as part of an Individual Plan. 3. Follow-up assessment. Reviewing AAC strategies. The following diagram illustrates the participation model and how it relates to your work role: ACTIVITY 1.17: How does this participation model compare to the data gathered in informal communication assessments within your organisation? What are the barriers which impact the client communication needs? Community Services and Health Industries Skills Council Ltd Page 18 of 76

20 Participation Model CHC08 Disability Behaviour Support Skill Set Phase 1 Today. Identify communication needs and assess barriers Assess Opportunity Barriers Policy Practice Worker skill, knowledge in AAC Client attitude, natural ability Opportunities to communicate Use Assessment of Opportunity Barriers or similar Identify Communication Needs Communication partners Disability, health and medication Literacy, numeracy, mobility and sensory Environmental Personal Use Client Communication Phase 2 Needs form, Family Tomorrow. Observation Sheet or Planning similar and implementing AAC strategies as part of an Individual Plan Assess Individual Barriers Assess current communication ASD characteristics AAC preferences ABC to understand behaviours of concern Use Assessment of Individual Barriers form or similar AAC Strategies for an Individual Plan Communication plan AAC strategy Task analysis Available AAC Tech skills of client and others Encourage Phase practicing 3 of skills Identify Follow-up. difficulties Recording Review AAC system strategies participation Successful? Yes No Community Services and Health Industries Skills Council Ltd Page 19 of 76 Follow-up

21 Section 2: Communication Assessment The main function of an assessment of a client s communication needs is to help the team of carers, health professionals, other workers, the community and yourself determine how to give them the best quality of life. Disabilities Unfortunately, when it comes to the majority of communication disorders, no one really understands their cause. However, we do have an understanding of how to help our clients maximise their speech and language development. Communication is complex. As a worker your role is to understand your client s ability in the following communication areas and help develop their skills. This requires you to recognise the following skills in your clients: Physical Skills. Includes mobility and sensory factors, allowing you to understand your client s body function and structure to determine the best positioning of any augmented or alternative communication system. Consider how much control they have of their limbs and body parts, and their mobility in accessing and using ACC equipment. Cognitive skills. Determine whether your client has reasoning and learning skills, to assess their ability to comprehend, process and remember. Identify their perceptive, sequencing and problem solving skills. Sensory skills. Determine your client s hearing and visual abilities. Other sensory factors need to be considered such as an aversion to smells, tastes, sounds, or touch. Social and emotional skills. Ascertain your client s ability to: o Recognise and understand their own feelings. o Manage their feelings in order to achieve their goals. o Feel empathy, allowing them to identify and understand the feelings of others. o Develop social abilities to relate to and influence others. ACTIVITY 2.1: Complete the table below by researching any disabilities your clients have and the impact on body function, communication skills and communication difficulties: Disability Cause Impact on Body Function and Structure Communication Disabilities Impact on Communication Skills Community Services and Health Industries Skills Council Ltd Page 20 of 76

22 ACTIVITY 2.2: What can cause a communication disability in a person with a disability? Coexisting Health Conditions Not only can a client have multiple disabilities they can also have medical and health conditions that coexist or occur concurrently. When the health condition causes pain, anxiety or fatigue this will often affect a person s ability to communicate. For example: Mental health. Mental health conditions such as anxiety, depression and dementia disrupt a person s ability to carry out daily functions, as they cannot think logically. It is estimated that mental health disorders affect people with a disability in the order of three to four times greater than the general population. Psychiatric disorders. Unrecognised or poorly managed mental health problems can contribute to poor communication. General health. General health conditions such as a virus, ear infections, broken limbs, heart disease, and arthritis can affect movement of limbs, mouth functions, speech, hearing and sight. This impacts on a person s ability to communicate. Research suggests that certain conditions do contribute to behaviours of concern, with the most common being infectious and pain related illness, mental health, sleep disturbance and seizures. Behaviour which presents as a concern may also be associated with physical pain or discomfort, particularly when your client experiences communication difficulties and they are unable to effectively indicate the experience of pain or discomfort to workers and carers through any other means. Failure to detect the presence of pain can lead to you making incorrect decisions and can lead to serious consequences for your client. It is important to consider whether a dental or medical consultation is necessary. Their assessment should also identify any medication that your client may be prescribed, the purpose of the medication, possible side effects, symptoms of overdose and complications. ACTIVITY 2.3: Complete the table below by researching the health and medical conditions common to your clients and the impact on body structure, communication and participation. Community Services and Health Industries Skills Council Ltd Page 21 of 76

23 Health Condition Severity Impact on Body Structure Impact on Communication Impact on Participation Literacy Literacy is the ability to read for knowledge, write logically and think critically about printed material. It is a lifelong, intellectual process of gaining meaning from print. The United Nations Educational, Scientific and Cultural Organisation (UNESCO) defines literacy as: "The ability to identify, understand, interpret, create, communicate, compute and use printed and written materials associated with varying contexts. Literacy involves a continuum of learning in enabling individuals to achieve their goals, to develop their knowledge and potential, and to participate fully in their community and wider society." Consider if your client can recognise written letters, words and phrases before developing ACC strategies. Numeracy Numeracy is the ability to reason with numbers and other mathematical concepts. A numerically literate person can manage and respond to the mathematical demands of life. Aspects of numeracy include number sense, operation sense, computation, measurement, geometry, probability and statistics. Numbers can be used to assist with communication if your client has an exceptional ability to remember codes or numbers. Colour Colour can be used to assist in sending messages to your client. For example, all words that match food could be written in blue so they make the connection. You need to be aware of whether your client has colour blindness. Colour blindness can be total or partial. Total colour blindness is much less common than partial colour blindness. There are two major types of partial colour blindness: difficulty distinguishing between red and green, and distinguishing between blue and yellow. Community Services and Health Industries Skills Council Ltd Page 22 of 76

24 Mobility Assessment of the client should always include consideration of any mobility skills and mobility support needs of the individual. These may be related to characteristics of a particular condition, age or developmental stage of the person and may impact on fine and/or gross motor skills and abilities. For example, motor disorders associated with cerebral palsy include impaired control of voluntary movement of limbs or of the whole body, disorders of balance, or loss of control of body posture. They can present in a range of behaviours from apparent inactivity to violent movements. Difficulties with fine motor skills may present as an inability to turn pages, use a keyboard or turn on a switch. Again, consider such characteristics in the context of the individual to better inform the development of a realistic and person centred Individual Plan. Sensory An example of sensory considerations are clients with ASD often experience sensitivity or aversion to particular smells, tastes, sounds, or tactile sensations. These will be different for each person. Assessment must include the identification of those individual specific sensory sensitivities or aversions and has implications for the design of appropriate AAC strategies. Touch cues included in an Individual Plan for a client with aversion to touch are wholly inappropriate and may be in breach of your organisation s policy. Sensory activities developed in consideration of the known sensory sensitivities of the client will often enhance quality of life and provide fulfilment not available elsewhere. Environmental Factors We all move through numerous environments each day, a move from one environment to another or from one activity to another in the same environment is known as a transition. Like all of us, clients experience life across a range of environments, including home, neighbourhood, community, work, day programs, school, recreational and social domains. Each environment will look, smell or sound different, may require different communication skills, involve different people or numbers of people, may be more or less crowded, be easily or less accessible, and be liked or not liked by the client. For clients with complex communication needs, the transition from one environment to another can be stressful and difficult. Transitioning a client may require planning in order to avoid confusion, distress or disappointment. Care must be taken to assess the characteristics of significant environments and activities to understand the impact of each on the client. Community Services and Health Industries Skills Council Ltd Page 23 of 76

25 Personal Factors CHC08 Disability Behaviour Support Skill Set It is important that you understand the personal factors that will affect your client s communication and use of AAC systems. These may include: Cultural and linguistic factors. This involves the cultural group which the client and their family identify themselves. These include social differences, beliefs and values from nationality, ethnicity, race, religion, gender, generation and socio-economic status. Life experiences. Their history of involvement with multiple services, across agencies, and over time. Knowing the life experiences of your client, such as grief, loss, adolescence, ageing and other life changes helps you identify why there may be barriers to successful communication. Preferences. Knowledge of your client s activities, pastimes and what they like to do. Learning Needs It is important to understand your client s learning preferences and those of their communication partners. Consider which of the following types of learner best describes your client: Auditory learners. Learn through listening and talking. They may have difficulty with reading and writing tasks, move their lips when they read and read out loud. They often learn when listening and talking to another person or a tape recorder. Visual learners. Learn best by seeing what they need to learn. There are two subchannels for visual learners: o o Visual-linguistic. Learn through seeing the written language, such as reading and writing tasks. They remember written information, even if it has only been read once. They like to write down directions and pay better attention to lectures if they see a PowerPoint slide with the information. Visual-spatial. Learners usually have difficulty with the written language and do better with charts, demonstrations, videos, and other visual materials. They easily visualise faces and places by using their imagination and seldom get lost in new surroundings. Kinaesthetic learners. Like to learn while touching and moving. This type of learner has two sub-channels kinaesthetic (movement) and tactile (touch). Kinaesthetic learners tend to lose concentration if there is little or no external stimulation or movement. When listening they move a lot. When reading, they like to scan the material first, and then focus in on the details to get the big picture. They typically use colour high lighters and take notes by drawing pictures, diagrams, or doodling. ACTIVITY 2.4: As a group, discuss your preferred learning styles and the impact it has on the way you learn. How can you apply this with your clients? Community Services and Health Industries Skills Council Ltd Page 24 of 76

26 Worker Skills and Knowledge of AAC Strategies Many people learn by modelling and being supported by others. Part of your role is to model the use of AAC strategies and be an example to your client. New technology can be daunting and it is easy to look at alternatives that feel more comfortable. This is natural behaviour. However, to model the principles of ACC we need to feel confident and support clients when they are out of their comfort zone. You can look for opportunities to enhance your knowledge of AAC devices by improving your technology skills, practicing with your client and learning together. ACTIVITY 2.5: Fill in the below Communication Needs Assessment based on clients you work with. How does this form compare to those used in your workplace? Community Services and Health Industries Skills Council Ltd Page 25 of 76

27 Identify Communication Needs CHC08 Disability Behaviour Support Skill Set Worker (your name): Date: Client s Name: Client s Age: Client s gender: 1. Other Communication Partners Family Parents, siblings, extended family Carers and friends Supportive relationships Others Health professionals, teachers, other agencies 2. Physical a. Client s disability/ies is best described by (consider all aspects of a disability): Disability Type Severity Mild/ moderate /severe Impact on Body Structure Impact on Communication Impact on Participation Expression and Receptiveness Physical (eg. cerebral palsy, spina bifida) Intellectual (eg. Down syndrome, global developmental delay) Community Services and Health Industries Skills Council Ltd Page 26 of 76

28 Psychiatric (eg. Bi-polar, schizophrenia, depressive disorders) Sensory (eg. hearing or vision impairment) ASD (eg. Asperger s, atypical autism, (PDD), autism disorder) ABI (eg. traumatic brain injury, stroke, amyotrophic lateral sclerosis) b. Other health conditions that can coexist for the client Health Conditions from the Past 12 Months Which Impact on Communication Type Severity Mild/ moderate/ severe Impact on Body Structure Impact on Communication Impact on Participation Expression and Receptiveness General Health Pain and discomfort (eg. toothache, headache, cramps, muscle soreness) Illness (eg. viral infection) Ongoing health conditions (eg. epilepsy, cardiac, Community Services and Health Industries Skills Council Ltd Page 27 of 76

29 cancer, arthritis) CHC08 Disability Behaviour Support Skill Set Community Services and Health Industries Skills Council Ltd Page 28 of 76

30 Mental Health Eg. anxiety, depressions, early onset of Alzheimer s or dementia CHC08 Disability Behaviour Support Skill Set c. Medications Last medical examination and outcome? Any medication, its purpose, duration, client s response? Last dental examination and outcome? 3. Literacy and numeracy ability, colour recognition, mobility impairments and supports, and sensory sensitivities Skills Literacy Skills Comments on Impairments Reading Writing Using Numbers Recognising Colour Mobility (eg. impairments and current supports such as wheelchair or needing arm supports) Gross Motor Skills Skills in controlling and moving upper body Lower body Fine Motor Skills Use of fingers for keyboard, writing Able to hold and carry weight, eg. pen Community Services and Health Industries Skills Council Ltd Page 29 of 76

31 Arms CHC08 Disability Behaviour Support Skill Set Able to turn and flick switches, eg. ipod Head Move eyebrows, eyes Use tongue, lips and cheeks for forming words Extra Supports Needed Sensory Sensitivities (what the client doesn t like) Touch Smell Taste Sounds Sights 4. Environmental Factors Environments Consider the different environments your client moves through in a day (eg. home, work, day program, shopping, visits, leisure activities) Client s Comfort Levels and Transfer Community Services and Health Industries Skills Council Ltd Page 30 of 76

32 Community Services and Health Industries Skills Council Ltd Page 31 of 76

33 5. Personal CHC08 Disability Behaviour Support Skill Set Cultural and Linguistic Factors Life Experiences Activities They Like To Do 6. Learning Styles Auditory Learn by listening and talking Visual Learn by seeing Kinaesthetic Learn by touching and doing Community Services and Health Industries Skills Council Ltd Page 32 of 76

34 Barriers to Communication CHC08 Disability Behaviour Support Skill Set An assessment will have been undertaken to determine if your workplace can provide the service for the client. Your role is to provide the service within your duty of care and the expectations of your role. As communication is vital, you will be expected to help develop the ACC strategies required by your client to give them the best quality of life. Remember to work within your role and seek clarification from your manager if you require further professional development. You can also make suggestions to your manager of possible solutions which can assist in the decision-making. There may be other legislation and policy creating barriers for people using ACC. For example; electronic devices such as video games will improve your client s hand-eye coordination, but are considered toys and not eligible for funding. You may be able to advocate for a change in the funding policies to have these games viewed as an assistive aid. The results of this communication assessment may suggest a referral to other services such as an interpreter, health professional or teacher is necessary. It may highlight resource issues related to funding of AAC and consideration of strategies where a risk of harm is identified. Client Attitude, Family Attitude and Natural Ability Other communication partners, especially peers and significant others, may have an attitude barrier towards using AAC strategies. For example, they may have a negative attitude, believing AAC and technology will not work for the client and may even hinder the client s development of communication. The client s family may have reduced expectations of the client preventing the client from even trying, and in turn reduce their participation opportunities. The family may simply not like technology refusing to invest in learning new skills. A negative attitude can reinforce the failures of the client and reduce their confidence to try something new. Awareness of these barriers can help you in focusing on who will be supportive of new strategies and allowing those with a negative attitude or poor expectations to see the success before suggesting they try the strategies. Another barrier could be cultural belief about disability. Western cultures tend to focus on individuals being independent, planning efficient use of time, being hardworking and focusing on achievements. Labelling the disability and conditions is understood to be a necessary step in obtaining services, medication, surgery and adaptive equipment which are generally valued as potential solutions. Client s Feelings It is also important to look at what helps your client feel happy, as well as what makes them sad, frustrated or angry when communicating. People learn best when they are relaxed and happy and often feeling sad, frustrated and angry can lead to behaviours of concern. Community Services and Health Industries Skills Council Ltd Page 33 of 76

35 History CHC08 Disability Behaviour Support Skill Set One of the most powerful barriers to communication is a person s experiences. If an experience is perceived to be negative they are three times more likely to remember it than a positive experience. Positive experiences are a motivator to repeat the experience, while repeated failure in attempts can lead to avoidance behaviours. This avoidance in communication can be called learned helplessness. Assess your client s history to determine any events which negatively impacted their communication, now causing a barrier. Also look for positive communication experiences and to try to replicate these, reminding your client about them. AAC Preferences Assessment of a person s preference of AAC systems will reduce barriers. These may include concerns about: 1. The portability, durability and appearance of the AAC system. 2. The time and skills required for the client to learn the system, especially for manual signing and technology-based systems. 3. The quality and ease of understanding of speech generating devices. 4. The naturalness of the communication achieved using the AAC system. 5. The cost of the AAC system such as computers, VOCA, PECS or attendance at signing courses. In your role as a support person for your client it is important you are aware of how to access information about funding requirements and aids. Your client and their families are considerably more demanding on AAC aids than the worker or the health professionals who recommend them, identifying concerns or idiosyncrasies about a device through everyday use, that a professional may not always notice. For example, many people who use AAC aids comment on the need for devices to speak languages other than English. This function would allow for private conversations, and is easier for communication partners to program. Environmental adaptations may be successful and simple solutions to communication access barriers, for example, altering the position of an electronic writing board, adjusting the height of the wheelchair arms so that the person can rest their arms closer to their face or creating storage space for AAC systems in a bag the person can carry and easily access. Community Services and Health Industries Skills Council Ltd Page 34 of 76

36 ACTIVITY 2.6: Fill in the below Assessment of Opportunity Barriers based on the clients you work with. Community Services and Health Industries Skills Council Ltd Page 35 of 76

37 Assessment of Opportunity Barriers CHC08 Disability Behaviour Support Skill Set a. Policy and practice in using AAC Considerations Y/N Comments Consent for purchase and use of AAC devices Who is giving the consent? Have the expectations of the what the service provider can offer been discussed with stakeholders (family, DHS) Specific expectations Are there any issues with the scope of the service provider: expectations of the family, health professionals, funding issues Provision for extra support by health professionals such as teachers, interpreters allocated Recommendations for support Any risks with using the current AAC strategies Risks and suggested solutions b. Worker skill and knowledge in AAC Your Skills as a Worker Y/N/Partly Comments 1. I have knowledge of AAC strategies and keep up to date with latest developments Community Services and Health Industries Skills Council Ltd Page 36 of 76

38 2. I have studied the characteristics of the disabilities and want to understand how I can improve the client s quality of life 3. I have knowledge of community and professional resources for clients CHC08 Disability Behaviour Support Skill Set 4. I work collaboratively with the families and other communication partners of my clients 5. I use different methods of collecting information about my clients (interviews, observations, questioning, accessing relevant information, other agencies, health professionals) 6. I monitor my professionalism by seeking feedback from others including my supervisor, clients and their family 7. I want to keep improving my work role and model the behaviour by planning and implementing an Individual Plan and reviewing it with my manager c. Client attitude and family attitude to AAC devices (natural keenness to learn) Attitudes Client attitude and beliefs about AAC Comments Family attitude and beliefs about AAC Natural interest in client to learn new skills Community Services and Health Industries Skills Council Ltd Page 37 of 76

39 Assessment of Individual Barriers CHC08 Disability Behaviour Support Skill Set Worker (your name): Date: Client s Name: Client s Age: Client s gender: 1a. Comment on Client s Communication Ability Communication Skill Physical How they use their body to communicate Observation Y/N Comments Give examples where possible Do they use their body? If yes which parts? Do they use their face to express themselves? If yes what expressions do they show? Do they form words easily using tongue and mouth? If yes what words do they use? One word 2-3 words One sentence A number of logical sentences Do they use any aids? If yes which ones? Cognitive Processing of information Do they understand verbal instructions? If yes, how do they show it? Community Services and Health Industries Skills Council Ltd Page 38 of 76

40 Do they understand written instructions? If yes how do they show it? Do they listen? If yes how do they show it and what do they look at? Can they summarise what they hear and say? Can they ask questions to check meaning? Can they ask questions to show interest? How long is their attention span? What distracts them? Emotional Understanding and showing of emotions Do they speak with emotion? Do they show emotions? If yes what emotions do they show? Do they understand others emotions? Community Services and Health Industries Skills Council Ltd Page 39 of 76

41 Social Interaction with others Do they start conversations? Do they show interest in others? Do they ask questions? 1b. What does the client do well in communication? 1c. What does the client need to improve on? 2 What aspects of communication make the client feel...? Happy and Relaxed Sad Anxious, Frustrated or Angry Community Services and Health Industries Skills Council Ltd Page 40 of 76

42 3 History 3a. Do you know if there are any life experiences which could have impacted on your client s communication in a negative way, for example, any incidents in the past, had hearing and lost it, lost a limb, abuse? 3b. Do you know if there are any life experiences which could have impacted on your client s communication in a positive way, for example, friendships, successful communication aids, other satisfying relationships? 4 Autism Spectrum Disorder (ASD) Characteristics ASD Characteristics Social Impairments Cannot understand the perspective of others or understand other viewpoints Most Times Sometimes Rarely Does not use eye contact, facial expressions, smiles when communicating Difficulty in creating relationships with others Does not enjoy social activities Difficulty understanding the emotions of others Difficulty participating in conversations Repetitiveness of words or actions, eg. repeating a person s name, rocking Needs very precise questions, eg. instead Community Services and Health Industries Skills Council Ltd Page 41 of 76

43 of what did you do today who did you speak with today Can t understand metaphorical meaning of words, eg. it s raining cats and dogs CHC08 Disability Behaviour Support Skill Set Lack of expression in speaking speaks in one tone Unusual use of words or phrases, eg. creates own words Sees whole situation but is confused with the sequence of events, eg. can understand the need to cross the road but cannot tell you the steps to cross the road Very strong interest in one or two areas, eg. one team in football Rituals in speech or behaviour, eg. only saying a person s full name or needing to have the room in a certain order before going to sleep Repetitive mannerisms, eg. hand flapping, finger flicking 5 AAC Preferences Aids Portability, Durability, Appearance Cost Time to Learn How to Use Quality of AAC Ease of Using AAC Strategy Adaptability of the Aids Community Services and Health Industries Skills Council Ltd Page 42 of 76

44 People Who Can Assist with Identifying the Needs of a Client Consulting with health professionals can assist in determining the best use of AAC strategies to achieve effective communication between your client and others. Following are details of some of the common health professionals or other personnel your client may already be working with, or who may be able to help you in assessing your client s needs: Aboriginal and/or Torres Strait Islander Health Worker Liaise between health care professionals and Aboriginal and Torres Strait Islander clients and their families to improve the quality of services provided. They help to bridge the cultural differences that can exist in health care settings, by acting as an interpreter to ensure both the health care professional and the client understand each other. These workers may also provide counselling and/or treatment for physical diseases or injuries. They may also make house visits to monitor progress, support clients and encourage the client and their families to learn more about health issues in general. An Aboriginal and Torres Strait Islander health worker needs: To be of Aboriginal or Torres Strait Islander descent. Good communication and negotiation skills. A good understanding of Aboriginal and Torres Strait Islander culture and health promotion. An ability to work independently and as part of a team. A commitment to improving the health of Aboriginal and Torres Strait Islander communities. Behavioural Consultant Role includes: Providing behaviour management consultation as a member of the treatment team Designing and directing the implementation of behaviour management intervention plans which are individualised for the client and family s needs. Providing intensive therapeutic services. Attending and participating in inter-agency service planning meetings. Providing on-site supervision and training to therapeutic support staff. Dietician Experts on food and nutrition who can help promote good health through proper eating. Dieticians offer advice on the type and quantity of food to promote good health, and provide diet plans for specific diseases. Community Services and Health Industries Skills Council Ltd Page 43 of 76

45 Diversional Therapist CHC08 Disability Behaviour Support Skill Set Use a person centred approach recognising leisure and recreational experiences can support, challenge and enhance the overall well being of individuals. Drug and Alcohol Worker Provide education and outreach to community members. They provide support to workers and clients, while assisting in exploring alternatives with clients who experience difficulties with alcohol and/or drugs. They work with clients who: Are under the influence or alcohol and/or drugs. Require emergency response intervention. Require needle exchange services. Require an advocate to act on their behalf. Drug and alcohol workers can also: Provide support and advice to the disability services workers of clients who are experiencing difficulties with drugs or alcohol. Assist in evaluation and preparation of reports requesting funding for programs and new projects. Arrange clients to be referred to other appropriate specialist professionals or support workers. Mental Health Worker Provide support services to people with mental health issues in the following ways: Assess the needs of clients with mental health issues. Provide support services to clients with mental health issues. Respond holistically to client issues. Respond to individuals at risk of self-harm or suicide. Identifying and respond to children and young people at risk of harm. Neuropsychologist Specially trained to evaluate and treat the ways in which alteration in brain functioning can affect a person s thought processes, behaviour and emotions. Occupational Therapist Assist people to improve their ability to perform tasks in their daily living and working environments for example; helping children with disabilities in school and social situations, aid skill development following an injury, and assist older adults with physical and cognitive changes. Community Services and Health Industries Skills Council Ltd Page 44 of 76

46 Pain Specialist CHC08 Disability Behaviour Support Skill Set A doctor who assists a person to manage their pain through a multidisciplinary approach. Pharmacist Licensed to prepare, compound and dispense drugs upon a written order from a registered practitioner such as a physician or dentist. A pharmacist will consult with and sometimes advise the registered doctor concerning drugs. Physiotherapist Treat a person s physical injuries through a range of passive and active exercises, targeting a person s specific physical needs. Psychiatrist A medical doctor who has completed at least five years of extra training in the prevention, diagnosis and treatment of mental illness and emotional disturbances, using a medical approach. Psychiatrists diagnose and treat conditions such as severe behaviours of concern (aggressive, acting out behaviour), depression, severe anxiety and schizophrenia (psychosis). They can treat the effects of emotional problems on the whole body as well as the effects of physical illness on the mind. The treatment approaches used by psychiatrists vary but may involve counselling for the client s carers, client therapy, medication (for example, antidepressants) or a combination of these. Psychologist A practitioner who has studied the mind and behaviour, understanding how people think. Most psychologists work directly with people to help them find better ways of coping or managing parts of their lives. They offer the following services: Counselling. To help cope with life s problems, such as grief or relationship issues Educational and developmental. To help with learning difficulties and help manage difficult behaviour. Clinical. To deal with mental health problems such as depression, anxiety and stress. Neuropsychology. To look at the biological causes of depression and other conditions. Assist with rehabilitation required after brain injury, stroke or degenerative brain disease. Community Services and Health Industries Skills Council Ltd Page 45 of 76

47 Respiratory Technician CHC08 Disability Behaviour Support Skill Set Helps clients who experience difficulty breathing learn to use various equipment and techniques to aid in clearer and more efficient breathing. They: Assist with testing such as measuring a client s lung capacity to diagnose respiratory ailments. A respiratory technician is also qualified to administer oxygen and various aerosol medications. Provide education on the benefits of quitting smoking, and information on preventing further respiratory disease, Work in emergency rooms, neonatal or paediatric intensive care units, and surgical units. Keep accurate records of a client s therapy and progress, setting breathing equipment to appropriate levels to control the flow of oxygen, and preparing various respiratory-oriented medical devices for use. They use a blood gas analyser, oxygen tents, oxygen masks, sputum collectors, suction kits, and nebulisers. Social Worker Health professionals who help individuals, families, groups and communities enhance their individual and collective wellbeing, and their capacity for social functioning. Speech Pathologist Evaluates and treats people with communication and swallowing problems using speech, writing, reading, signs, symbols and gestures. ACTVITY 2.7: What role and function might a speech pathologist have in the development, implementation and maintenance of augmentative and alternative communication strategies and devices for a client you work with? Wound Consultant A wound consultant is usually a nurse who is trained to undertake an assessment of a person, their wound and any other factors which may impact on the ability of the wound to heal. The consultant will then provide advice and treatment options. Community Services and Health Industries Skills Council Ltd Page 46 of 76

48 ACTIVITY 2.8: Which health professionals have you worked with in the past with your clients? What is the referral process? Community Services and Health Industries Skills Council Ltd Page 47 of 76

49 Communication with other stakeholders CHC08 Disability Behaviour Support Skill Set Effective communication between the client s family, carers and disability services workers is important to maintain all aspects of the client s wellbeing. This communication is particularly important in terms of AAC systems; for the systems to be useful, the organisation and the family must use the same form of communication. With a consistent approach to communication from all stakeholders, the client can effectively engage in communication. Disability services workers are required to document factual, clear file notes in relation to the client s communication. For example, if a client is extremely tired on a particular day, this can affect their ability to communicate compared to other days. Or the client s communication aid may not be working properly; they may have been introduced to a new device or a new communication plan. Using detailed file notes all staff within an organisation have an understanding of what is happening with the client s communication abilities. This information can be passed on to the client s family through their communication books. In this way both the family and the workers can relay current information and keep each other updated. Any difficulties or achievements should be noted in both the client s file notes and their communication books. Client notes should be updated on a daily basis, with every person who has worked with the client throughout the day entering their notes. Notes can also be written in a communication diary in the case of 24/7 accommodation support. ACTIVITY 2.9: What is the process for documentation in your workplace? Family Part of providing support to your client is to consult with the client s family and significant others in their life. One way of involving the family in the development of a communication plan is to ask for their observations of your client s communication needs. This will give you another perspective on your client s communication needs, preferences and current abilities which you may not otherwise see. Community Services and Health Industries Skills Council Ltd Page 48 of 76

50 ACTIVITY 2.10: How could you use this Family Observation Sheet with your clients? Community Services and Health Industries Skills Council Ltd Page 49 of 76

51 Family Observation Sheet CHC08 Disability Behaviour Support Skill Set Your name: Relationship (eg. mother, brother, uncle, carer): Person who has the disability and complex communication needs: Strongly Agree The family member who has the disability Expresses emotion in an appropriate way Communicates easily Communicates with siblings Communicates with parents Communicates with peers Participates in daily activities Is independent in looking after their core needs, eg. dressing, showering, cooking Communicates on a variety of different topics When I communicate with them I know how to enhance their communication I know how to help them when they are having trouble communicating The staff of the service provider Supports them to improve their communication Responds to the needs of the person Use creative and effective ways to aid the person s communication Includes family members in the decision-making process when necessary Helps us use communication strategies Agree Unsure Disagree Strongly Disagree N/A Community Services and Health Industries Skills Council Ltd Page 50 of 76

52 at home CHC08 Disability Behaviour Support Skill Set Community Services and Health Industries Skills Council Ltd Page 51 of 76

53 Section 3: Implementing AAC Strategy Using AAC systems with your clients requires a detailed understanding of the system by you, your client and others in your client s life, as well as the ability to use these systems in a variety of situations. You will also be using those systems to communicate questions, tasks and directions, to support your client in the community. Each AAC strategy involves steps for the client to achieve their goal, and understanding the steps helps us to monitor the progress and learning development of our client. These strategies are also recorded in the clients Individual Plan. ACTIVITY 3.1: Thinking of the clients you work with, fill in the below Communication Plan for the clients Individual Plan. Community Services and Health Industries Skills Council Ltd Page 52 of 76

54 Communication Plan CHC08 Disability Behaviour Support Skill Set Date Individual Plan Use of AAC Strategies Strategies From Meeting (those in attendance) Long-term Goal Changes to the Environment Teaching the Client and Others Recommendation: Short-term Strategies Immediate Response Strategies Short-term Goals of Individual Plan Use of AAC Strategies Client s views/requests/opinions Long-term goal Community Services and Health Industries Skills Council Ltd Page 53 of 76

55 Short-term goals Strategies Person/s Responsible CHC08 Disability Behaviour Support Skill Set By When Resources Required Now we have completed the Communication Plan we are aware of the client s needs. The next stage is to break down each short-term goal into the necessary steps to teach and reinforce the skills with the client. We need to understand the task (the short-term goal) and its objective. We also need to ensure we have the resources and skills to teach the steps. ACTIVITY 3.2: Why is it important to understand a client s communication level before teaching a new skill? Prompting Prompts assist giving instructions to your client. A prompt induces a person to perform a behaviour which would not have occurred otherwise. The prompt is an instruction which happens before the change of behaviour, and should be used as part of a three step system: 1. Prompt. 2. Reinforce. 3. Fade. In order to guide your client to have independence with their new skills, you need to model each step of a task and offer prompts to your client. The types of prompts you can use are described below: Community Services and Health Industries Skills Council Ltd Page 54 of 76

56 Modelling CHC08 Disability Behaviour Support Skill Set A model is simply an example, and modelling an AAC strategy is most effective for all learners as it is visual, auditory and kinaesthetic. When you are using your client s AAC system, whether that system is made up of signs, communication boards or symbols, you model the communication by: Pointing out the main words that you say on the AAC system. When your client communicates something, show them how they could communicate that word or phrase using their AAC system. Whenever the client uses their AAC system, model their message back to them, but in a slightly longer form. For example, if your client points to the symbol for book on their AAC system, you would point to want book and then say You want a book. Then you point to the symbol for get book and say OK, I ll get you a book. Model only a few more words per utterance than the client uses so that your model is not too hard for them to follow. The benefit of modelling as a way to help your client with their AAC strategy is that it can be used anywhere at any time. This makes modelling a very powerful teaching technique as there doesn t have to be designated modelling time. You can also model other communication skills such as: Language skills. Model putting two or three words together to form phrases, then sentences. Social skills. Model initiating a conversation, taking turns, listening to the other person, knowing when to speak, when not to and what to talk about, with whom, when and where. Strategies to keep conversations going. Model how to manage misunderstandings, using different AAC systems in different situations, or showing the client that they correctly (or incorrectly) interpreted the message. Verbal Prompts Words to explain the correct switch, picture or icon on the ipad for example. In general, prompts and cues are important to the teaching process and used frequently, whether to name an action, describe the communication or encourage the person to have a go. However, take care to ensure your client does not become too dependent on the prompts and will not do the action without them. Physical Prompts When people with CCN are first learning to communicate using the picture exchange system PECS, they often require touch cues that give additional information to spoken words. The touch cue could be an extended, open hand cue, pointing or a piece of clothing. Physical prompts may require hand-over-hand assistance to show how to use the symbols, icons and keyboard by standing behind your client and physically positioning their hand. Community Services and Health Industries Skills Council Ltd Page 55 of 76

57 Another physical prompt is to use a torch or infrared beam to show the icon, switch or card they need to use. Like verbal prompts, it is important to fade physical prompts as soon as possible so the person does not become dependent on them. ACTIVITY 3.3: Give an example of how you have used prompts when working with a client. Pauses Another part of the instruction process is to use pauses after each prompt. The length of the pause depends on the person with the complex communication needs and their ability to interpret and respond to signals. In the pause you look for a response any movement or vocalisation that appears to be deliberate. If the signal your client gives is acceptance, you have permission to move forward. If the person gives a rejection signal, you may stop the instruction and try again exploring an alternative way of moving forward. If there is no signal, repeat the cue and pause again. If there is still no signal it may mean you need to stop as the client is no longer engaging with you or it could mean the client is OK and waiting for you to proceed. This is when your knowledge of the client benefits the situation. If you are uncertain you can repeat the previous steps as a way to reinforce the learning. If your client is still engaging you can then move forward to the next step. Independence The purpose of prompting is to encourage behaviour then reinforce that behaviour. It is important to give the client time to respond, especially if they need to process information. You present the prompts or instruction and wait a few seconds before prompting again. This will clarify if your client is attempting the correct response, helping you determine which prompt level to use. As the target behaviour begins to appear more regularly, you can fade out your prompting. When your client communicates without modelling, verbal or physical prompts they are independent in achieving the task. Reinforcing the behaviour through encouragement and celebrating achievements motivates them to continue using the new skill when they are tired and it takes more effort. Community Services and Health Industries Skills Council Ltd Page 56 of 76

58 ACTIVITY 3.4: How can you assist clients with complex communication needs to actively participate in their community? ACTIVITY 3.5: Fill in the below Task Analysis - Prompting form based on a client you support. Include the prompts at each step. Task Analysis Prompting Steps Modelling Verbal Prompts Physical Prompts Independent Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Community Services and Health Industries Skills Council Ltd Page 57 of 76

59 Environment CHC08 Disability Behaviour Support Skill Set There are many factors within a person s environment that impact their learning and use of AAC strategies. Creating the best learning environment is part of your role in supporting your client. An environment is made up of the setting and the interactions within the environment. Create the optimum setting for your client to use their AAC systems: Meaningful activities. Make the activity meaningful and enjoyable, for example Megan loves painting and stories. Space. Ensure there is enough space to learn, move and set up equipment - Megan would need ample space for painting. Variety. Encourage a variety of settings in which to practice skills Comfortable space. Ensuring the client is relaxed in their position and space. Appropriate equipment. Having materials and equipment that are age, culture and gender appropriate that the person is able to use it. Limit distractions. Ensuring there is nothing that could draw your client s attention away from their communication tasks The interactions your client has in an environment will also influence their success with their AAC system: Positive interactions. Ensure your client has many positive interactions with others who are assisting with learning -give encouragement and incentives. Belief in the ability to learn. If you believe the person can do the new tasks you inspire them to achieve more observe and acknowledge any signs of improvement and learning. Rapport and enjoyment. Have fun together and enjoy the process as well as the outcome be aware it may take time to learn. Existing skills and strengths. Build on existing skills as the foundation for new skills Other learners. Have other communication partners learn new tasks at the same time, for example the client s family and other workers. Opportunities to learn. Create regular routines for learning and look for opportunities to practice. Choice. Encourage your client to have control of their learning allow them to choose the time of day to learn, when to have a break, add their own ideas, when to stop for the day and when the next lesson could be. ACTIVIY 3.6: What environmental factors will help you to optimise the use of communication opportunities and strategies for your clients? Community Services and Health Industries Skills Council Ltd Page 58 of 76

60 ACTIVITY 3.7: Fill in the below Task Analysis Environment Form for a client that you have worked with. Task Analysis Environment Environment Settings: Environment Meaningful activities Considerations and Changes Space Variety Comfortable Space Appropriate equipment Limit distractions Interaction Environment: Positive interactions Belief in the ability to learn Rapport and enjoyment fun Community Services and Health Industries Skills Council Ltd Page 59 of 76

61 Existing skills and strengths CHC08 Disability Behaviour Support Skill Set Other learners Opportunities to learn Choice in learning Community Services and Health Industries Skills Council Ltd Page 60 of 76

62 Reinforcement CHC08 Disability Behaviour Support Skill Set Reinforcement is the most important strategy employed in behaviour management. Simply stated, reinforce means to strengthen. This is exactly what reinforcement does to human behaviour it strengthens the behaviour. Reinforcement is a cause-and-effect relationship between a situation and some behaviour which the client has performed. If you feel good after a day at work but cannot connect this feeling with any behaviour, you are not experiencing reinforcement. No behaviour is being strengthened. But if you feel good and attribute this feeling to helping a client learn a new step in their task analysis or completing your reports in your shift, you are experiencing reinforcement. If you understand the teaching and documentation completion caused you to feel good, then you will strive to achieve this more often. Note that this change in your behaviour would occur even if you were wrong in your belief about what caused the good feeling. As long as you have a clear perception it is likely to have an impact on your behaviour. This is the principle behind reinforcement. Reinforcement makes a person feel good, therefore having an effect of strengthening (or increasing) the behaviour which preceded the reinforcement or seemed to cause the pleasant situation. There are three ways for a pleasant situation to occur: 1. Type I Reinforcement. When something pleasant is added to a person's existence. The addition of something nice provides a pleasant situation, for example, praise or being allowed to do more of the activity. 2. Type II Reinforcement. A person discovers that something unpleasant has been removed. If something bad has been happening to you and it suddenly stops, you would naturally say that this represents a good situation. For example, no more self harm, aggressive behaviour or being scared. 3. Type III Reinforcement. A person is able to avoid an unpleasant situation which was very likely to occur this normally represents a good situation. For example, avoiding self harm prevents pain and stress to the client and others whom they love. In all three types of reinforcement, the client receiving the reinforcement feels good. That's because all three have the same effect, they are different ways to create a pleasant situation. The distinction among the three types is that each represents a different reason for feeling good. There are two good reasons to become familiar with all three types of reinforcement. First, you will often be looking for a strategy to strengthen a behaviour, and it will be useful to look for all three types as possible sources of reinforcement. Secondly, all three types may occur organically, and if you wish to avoid accidentally reinforcing undesirable behaviours, you will need to be able to identify the accidental use of any type of reinforcement. Community Services and Health Industries Skills Council Ltd Page 61 of 76

63 ACTIVITY 3.8: Give an example of Type I, II and III Reinforcement you have observed in your workplace. Community Services and Health Industries Skills Council Ltd Page 62 of 76

64 Motivation CHC08 Disability Behaviour Support Skill Set Your clients will have a greater chance of success when you use strategies which make the learning fun, non-judgemental, relevant and timely. Greater emphasis is placed on presenting particular strategies to your clients which: Make the process as enjoyable as the outcome. Allow mistakes or non-successful attempts to be opportunities for encouragement. Ensure the task is interesting and appropriate for the client s age and ability. Adjust learning outcomes to make them achievable for the client, for example start by adding one digit numbers instead of three digit numbers. Change the characteristics of the task, for example if the task requires your client to read something and they are not literate or are vision impaired, use audiovisual aids. Break each task into smaller sub-tasks. Give short, clear instructions. Give the client time to process the information. Provide additional structure and assistance in the form of concrete examples, modelling or physical and verbal prompts. Use visual supports such as word lists, pictorial time tables or self-management charts. Provide frequent and specific feedback for reinforcement and correction. Provide opportunities for both guided and independent tasks and learning. Your responses, prompting, reinforcers and incentives give your client feedback in their progress, keeping them motivated. ACTIVITY 3.9: As a group, discuss ways you can reinforce communication by timely and appropriate responses? How can you implement this in your workplace? Intrinsic Motivators Success is one of the best reinforcers of new behaviour because the person is motivated intrinsically, without external inducement. They WANT to do the behaviour and repeat it correctly again and again. This is a natural motivator. Intrinsically motivating activities are those a person will engage in for no reward other than the interest, enjoyment and wanting to get the benefits of learning a new skill. For example a client with complex communication needs is motivated to use a new behaviour, because that new behaviour gives them what they want, such as: Community Services and Health Industries Skills Council Ltd Page 63 of 76

65 Positive attention from others. Access to preferred activities or objects. Reduced feelings of arousal, anxiety, disappointment or frustration. Sensory stimulation, they feel good about themselves. Intrinsic motivators are detailed in the table below: Intrinsic Motivator Challenge Curiosity Fun Description People are best motivated when they are working toward personally meaningful goals when what they learn has a purpose. Something attracts the person's attention, they want to know and learn more. When people are happy, having fun and feel relaxed they are more open to learning. Reinforcer Set personally meaningful goals. Make attainment of goals probable but uncertain. Give performance feedback, often. Relate goals to how the person feels good about themselves. Stimulate sensory curiosity by clapping, smiling, a high five, playing music or doing a dance Stimulate cognitive curiosity by making a person wonder about something, ask questions when they don t get the result they want (i.e., stimulate the learner's interest). Make a game out of learning. Mistakes are a fun and different way of getting the learning result. Recognition and feedback Control Learners feel satisfaction when others recognise and appreciate their accomplishments. People have a basic tendency to want to control what happens to them. Recognition requires that the process or end result is seen and the learning is effective. Giving feedback on the effort involved, how the task was done as well as the result motivates others to continue the learning and behaviour Make clear the cause-and-effect relationships between what the person is doing and things that happen in real life. Remind the person how learning the new skill will help them get what they want have friends, feel good with other people, stop the self Community Services and Health Industries Skills Council Ltd Page 64 of 76

66 harm, feel happy Offer options to the person so they can choose what they want to learn and how they will learn it. Competition Cooperation Laughter Learners feel satisfaction by comparing their performance favourably to what they have done in the past. A person feels satisfaction by teaching others the new skill. Person is enjoying the activity, smiles, laughs at mistakes and makes jokes. Competition occurs naturally. Competition with others can lead to failure and be a strong demotivator, avoid negative comparisons. Focus on personal competition and personal improvements. Cooperation occurs naturally. Working with other communication partners encourages the learning. Teaching other communication partners the skill embeds the learning. For example, Megan teaching her Mum how to use the ipad helps Megan show her success, reinforces the learning and encourages communication. Focus on the fact that everyone makes mistakes including football players, people on television, and it is how people learn they keep trying and keep smiling. Mirror their laughter and smiles so you laugh with them and they don t misinterpret your laughter as laughing at them. Extrinsic Motivation Extrinsic motivation reflects the desire to do something because of external rewards, where those rewards could be material such as a desired object, or emotional such as praise or a feeling of achievement. People who are extrinsically motivated may not enjoy certain activities and may only wish to engage in them if they receive some external reward. Extrinsic motivators can be both positive and negative. A positive extrinsic motivator will be in the form of either a material or emotional reward. A negative extrinsic motivator will be in the form of withdrawing a reward if the task isn t completed. Both positive and negative extrinsic motivators are crude, lazy and often ineffective at motivating people. They focus the person on the reward or lack of, rather than on the action. Community Services and Health Industries Skills Council Ltd Page 65 of 76

67 If the extrinsic motivator is not used, the person will not complete the task or use the desired behaviour. At the same time, extrinsic motivators which supplement intrinsic incentives do not necessarily have to have the same ineffective outcome. If they are done properly, extrinsic motivators can enhance intrinsic motivation iii. For example, if your client is unwilling to practice using their AAC system, preferring to play their favourite game, you can encourage them to play a different game which involves interaction, or practicing another skill which will assist with their learning. This is an extrinsic motivator which will begin to relax your client and stimulate their thinking. You can make the link to how this skill is used in their learning, and gradually introduce the learning activity, going back to the game when they lose interest. Eventually you will not need to use the game to introduce the activity, as the client now considers the activity a game. ACTIVITY 3.10: What are some intrinsic and extrinsic motivators you have used positively and effectively with your clients? Stimulation to Learn People tend to learn best at a medium level of arousal. This means that if your client is at a very low level of arousal, you should do things that are likely to increase arousal. On the other hand, if learning is impeded by an excessively high level of arousal, then you need to do things that are likely to reduce the level of arousal. You can influence the level of arousal in the following ways: Introduce topics in an interesting manner Use humour and games Speak expressively and enthusiastically Give breaks every 10 minutes for those with a short attention span. Incidental Learning Incidental or informal learning happens outside of the learning sessions when you are giving instructions, often occurring outside the home. When your client is successful in using their Community Services and Health Industries Skills Council Ltd Page 66 of 76

68 new skill when shopping, out in the community or in the day program, they have shown they have adopted the new skill and can adapt it to different situations. This is called generalisation. Performance Over Time 75% I Adopt and Adapt Informal Learning 20% 5% I Can Do I Know Study by Sally Anne Moore, Digital Equipment Corporation Time to Performance Formal Learning ACTIVITY 3.11: How can you motivate a person with a disability to learn a new communication system that is going to require long-term effort? Monitoring Long-term responsibility of monitoring implementation is also part of the support team s role. Monitoring the client s progress ensures everyone involved understands the requirements of the Communication Plan, ensuring those strategies are implemented correctly and consistently. Monitoring addresses all aspects of plan implementation Issues need to be addressed as they occur and as a disability services worker, you will probably have significant contact with your client. Notifying your manager and the client s health professionals is essential if you have any concerns. Adjustments can be made to the plan as needed such as modifying the long and short-term goals on the communication plan. Community Services and Health Industries Skills Council Ltd Page 67 of 76

69 ACTIVITY 3.12: How can you make sure there is consistent implementation of communication strategies in your workplace? ACTIVITY 3.13: What forms and processes does your workplace use to monitor and review communication strategies? You can monitor how effective AAC strategies and aids have been by using the following techniques: Observation Note all aspects of the communication, for example is the client s learned method of communication effective, are they having trouble with the method or are others having difficulty understanding them? You are able to observe the communication strategies and aids which are working or not, in a relaxed atmosphere or situation. Informal Discussions with the Client These discussions will help you directly assess the client s communication needs. An informal discussion could be part of your day-to-day interactions with the client which provide opportunities for informal learning. Remember that a person with complex communication needs cannot express their requirements as easily as others because of their limited language and can be subject to abuse or neglect. You have a duty of care to share any concerns so that changes to your client s mood and wellbeing are constantly monitored and rectified when needed. Community Services and Health Industries Skills Council Ltd Page 68 of 76

70 Formal Meetings CHC08 Disability Behaviour Support Skill Set The progress of a communication plan is discussed with the client and their support team at regular intervals. Changes and adjustments can be made to accommodate your client s needs more effectively. Planning Meetings A planning meeting may be an Individual Planning meeting, a behaviour meeting or an intake meeting. These meetings develop strategies to highlight a client s needs through either a holistic approach (focus on person centred planning), or to target a specific area of the client s life (communication or behaviour). ACTIVITY 3.14: Who is involved in planning meetings in your organisation? Community Services and Health Industries Skills Council Ltd Page 69 of 76

71 Opportunities for Review CHC08 Disability Behaviour Support Skill Set Monitoring your client s use of their AAC strategies will assist you to take into consideration the opportunities available for your client to increase their communication vocabulary. This may involve procedural reliability checks for support workers, but should also promote sharing of information and feedback, through regular forums such as family/team meetings. Again, data collection is part of your role in this stage Contextual Learning Difficulties Contextual learning is how your client uses their new skill in a range of different contexts or environments such as when shopping, at home or in the park. This is taking the learning out of the formal process into meaningful applications in the client s life. Contextual learning is a new task and again needs steps to instruct your client in using the skills. There are more factors outside of your control in contextual learning environments, and more distractions for your client. These contexts can present difficulties that impact on their learning ability. ACTIVITY 3.15: Fill out the below Contextual Learning Difficulty Table based on a client you work with and brainstorm possible solutions you could implement. Contextual Learning Difficulty Table Difficulties Contextual Difficulties e.g. Moving the learning to different contexts such as shopping centres or the family home Possible Solutions Practical Learning Difficulties Community Services and Health Industries Skills Council Ltd Page 70 of 76

72 Often, using AAC strategies involves problem-solving. For example, if you want to encourage a client to use their ipad with the PECS in the shopping centre, in the park and wherever she is feeling anxious or afraid, you need to consider how she will remember to bring it with her. There may be practical problems which need solving for your clients. ACTIVITY 3.16: Fill out the below Practical Learning Difficulty Table based on a client you work with and brainstorm possible solutions you could implement. Practical Learning Difficulty Table Practical Difficulties What can go wrong with the AAC system or strategy Possible Solutions Community Services and Health Industries Skills Council Ltd Page 71 of 76

73 Resource Difficulties and Other Significant Factors Resource difficulties and other factors are those which were not considered during the planning stages of developing your client s AAC strategies as it was not possible to know them. These difficulties may include extra expenses, maintenance and other resources which are needed. ACTIVITY 3.17: Fill out the below Resource Difficulty Table and brainstorm possible solutions you could implement. Resource Difficulty Table Difficulties Resource Difficulties e.g. Extra expenses, maintenance Possible Solutions Community Services and Health Industries Skills Council Ltd Page 72 of 76

74 Identifying Opportunities to Increase Communication Vocabulary By identifying areas your client could experience difficulties using their AAC systems, you will also be able to see new opportunities to increase their skills, expand their network of communication partners and develop more opportunities. ACTIVITY 3.18: Fill out the below Vocabulary Opportunity table based on a client you work with. What strategies can you develop? Vocabulary Opportunity Table Opportunities to Increase Vocabulary How to Develop Opportunities Monitoring Satisfaction and Progress Monitoring may involve procedural reliability checks for support workers, but should also promote sharing of information and feedback, through regular forums such as family/team meetings. ACTIVITY 3.19: What processes does your workplace use to obtain client feedback and measure satisfaction? What could be improved? Community Services and Health Industries Skills Council Ltd Page 73 of 76

75 One way to do this is through good record-keeping. Keeping regular, informative and objective progress notes is necessary to keep the support team informed and allow you to continually reflect on the progress of your client. Progress notes need to be kept which accurately and professionally record all communications relating to work being undertaken in accordance with the Individual Plan. They need to be updated after each contact with the client and be accessible to line management. Maintaining the confidentiality of a client s progress notes in accordance with organisational policy is essential. It is important that progress notes identify issues of concern in the work process as well as particulars of the matter being recorded and include a record of conversations and contact with the client about any issues of concern. Care should be taken to ensure progress notes are written objectively and professionally with no judgments, just facts including any notes made via or attachments. ACTIVITY 3.20: Fill in the Progress Notes below based on an example from your workplace. What information can you report back to the team? Name: Task Analysis Progress Notes Date Comments Initials Community Services and Health Industries Skills Council Ltd Page 74 of 76

76 Measuring your client s satisfaction with their AAC strategies and services is the key to obtaining outcome data and making progress. Satisfaction refers to the clients, their family, and their opinion of the impact the service you are providing is having. ACTIVITY 3.21: How do collect feedback from clients and carers in your workplace? What do you do with it? ACTIVITY 3.22: If you can see that something is not working for a client, what would you do? Who could you work with to overcome barriers? ACTIVITY 3.23: Based on what you have learned, what changes will you implement in your day-to-day work role? How can you apply this is the wider community? Community Services and Health Industries Skills Council Ltd Page 75 of 76

77 i Speech Pathology Australia Speech Pathology Australia response to research paper Putting Children First...Planning for the Future [Online, accessed 24 Oct. 2011]. URL: data/assets/pdf_file/0018/17271/speech_pathology_aust_submi ssion.pdf ii iii Hobbs, 1992 Cameron & Pierce, 1994 Community Services and Health Industries Skills Council Ltd Page 76 of 76