The Middle Tennessee State University McNair Research Review

The purpose of this study is to examine caregivers’ attitudes toward augmentative and alternative communication (AAC) used by adults with mental retardation. Specifically, the study investigated the amount of training the caregivers received about their clients’ AAC intervention plans and the caregivers’ self-efficacy to facilitate communication from their clients. The survey was administered to four caregivers. Although the caregivers were confident in their own abilities and their clients’ abilities, the results indicated that the caregivers were uncertain as to how the training they received improved their skills to implement their clients’ communication plans. Benefits of the investigation included the identification of factors which may influence the design, development and implementation of future AAC training for caregivers. Caregivers’ Attitudes Toward Augmentative and Alternative Communication Augmentative and alternative communication (AAC) is defined by the American-Speech-Language-Hearing Association (1989) as “an area of clinical practice that attempts to compensate, (either temporarily or permanently) for the impairment and disability patterns of individuals with severe expressive communication disorders” (p. 107). According to Light and Kent-Walsh (2003), an estimated two million communicatively disordered Americans may require AAC. Many of these Americans are adults with mental retardation. AAC devices may help individuals with mental retardation to enhance their abilities to communicate functionally with others. For example, pointing to a picture of a cup on a communication board to indicate the individual is thirsty is known as functional communication (Parette, 1994). There are two different categories of AAC devices: unaided and aided. Unaided AAC modes, including manual signs, graphic symbols, and object systems have been validated as effective communication options for people with mental retardation (Schepis & Reid, 2003). Aided devices include tangible objects, and representational symbols such as photographs, picture communication symbols, and pictogram ideogram communication. Selection of an appropriate AAC device depends on a number of client factors such as (1) physical and cognitive abilities; (2) the social support system; (3) the daily routine; (4) cost; and (5) staff training (Schepis & Reid, 2003). Augmented language learning is a successful method for communicating with persons having mental retardation. For example, a facilitator may say, “Let’s get your gloves and go for a ride.” The facilitator might then activate the symbol for “gloves” and “ride” (Beukelman & Mirenda, 1992). Overall, if the AAC device is to be useful, it must be easy to use, linguistically powerful, flexible, and consistent with the user’s cognitive level (Beukelman & Mirenda, 1992). Lasker and Bedrosian (2000) defined the acceptance of AAC systems, as “how and to what degree an AAC system is integrated into the life of the user” (p.108). Communication partners provide social opportunities for AAC users (Huer & Lloyd, 1990). Benefits of AAC use for adults with mental retardation include behavior management for externalized acts of aggression (Baumgart, Johnson, & Helmstetter, 1990). AAC can be used along with functional communication training, which is an intervention strategy used to support individuals with challenging behavior (Mirenda, 1997). Synthesized generated devices for nonverbal individuals may increase the number of opportunities for social interactions (Schepis & Reid, 2003). The synthesized speech device will provide a more natural form of output versus an unaided method. Yet another benefit of AAC intervention with adults with mental retardation is improved choice-making in the environment through vocabulary selection (Beukelman & Mirenda, 1992). Providing the individual with a choice is an important aspect of respecting the individual’s rights. Providing MCNAIR JOURNAL • MIDDLE TENNESSEE STATE UNIVERSITY • SUMMER 2005 9 choices may give the individual power and may foster a sense of self-esteem. A disadvantage to AAC use may be found in the case of synthesized speech output, a less natural and less intelligible AAC device. People who are unaware of the AAC user’s mode of communication may be unable to decode the message (Higginbotham, Scally, Lundy, & Kowarsky, 1995; Schepis & Reid, 2003). AAC has been formally recognized as an area of clinical and scientific interest within the field of speech-language pathology and other fields for the past two decades (Gorenflo & Gorenflo, 1991; Huer & Lloyd, 1990). For more than a decade there has been a movement in the field of mental retardation to deinstitutionalize individuals with mental retardation to ensure they reside in the least restrictive environment. Since the deinstitutionalization of hospitals, there has been an increase in the number of community living homes. Thus, the need for individuals to develop functional communication skills in their environment has increased (American Speech-Language-Hearing Association, 1990). “The ability to express feelings, interests, preferences, desires, and needs in some mode of communication is critical to the quality of life for all people” (McCarthy, McLean, Miller, Paul-Brown, Pomski, Rourk, & Yoder, 1998, p. 2). Historically, communication boards were viewed as a last resort, rather than a technique that would maximize the communication environment (Vanderheiden & Yoder, 1986). People with severe and profound mental retardation have only recently been recognized as appropriate candidates for AAC intervention (Beukelman & Mirenda, 1992). People with severe mental retardation were among the most devalued and disenfranchised citizens living in any country in the world. More recently, work from agencies such as the Association for Persons with Severe Handicaps and current legislation under the Americans with Disabilities Act of 1990 and the Assistive Technology Act of 1998 have given individuals with severe and profound intellectual disabilities the opportunity to live with greater communication abilities. In the past, AAC intervention focused exclusively on the individual. However, it is now known that the communication plan needs to be used, facilitated, and understood by significant people and others in the client’s life (e.g., caregivers, friends and family members). According to Schepis and Reid (2003), the AAC user’s social support system must be able to interpret the communicative intent in order to interact effectively with the individual. Currently, the intervention strategies not only improve the communication skills of the individual, but also focus on the AAC user’s speaking partners (Beukelman & Mirenda, 1992; Huer, & Lloyd, 1990; Light & Binger, 1998; Light, Dattilo, English, Gutierrez, & Hartz, 1992; Schepis & Reid, 2003). As outlined by the American Speech-Language Association (1990), speech-language pathologists are required to provide training for family members, significant others and staff, which may include skilled trainers, communication assistants, paraprofessionals and other team members. The roles and responsibilities also include the identification of appropriate AAC candidates, determination of appropriate AAC systems for clients, development of extensive intervention plans for clients to achieve functional communication, implementation of intervention plans, evaluation of the intervention outcomes, evaluation and awareness of new AAC technology and strategies, advocacy in the AAC area, provisions of intervention to professionals and consumers, and coordination of AAC service. Thus, direct supervision and training from the speech-language pathologist is critical to the success of the individual’s functional communication intervention plan. According to Kraat (1985), simply providing access to the AAC device will not ensure the development of communicative competence by individuals. Training of the individual AAC user and the caregiver also must be completed. Caregiver training ensures that the individual understands how to operate and maintain the device, understands body positioning and other physical considerations, and understands the applications in different settings. This leads to the selection of appropriate vocabulary, the knowledge of how to create and identify functional communication learning opportunities, the ability to use appropriate teaching strategies, and how and when to prompt and respond to individuals using AAC (Schepis & Reid, 2003). Without adequate training, functional communication will not be enhanced (Schepis & Reid, 2003). Research by Reid and Parson (2002) contributed to two important factors that influence successful use of AAC. These factors are (1) basic knowledge about the rationale of the AAC use, specific to the individual, including understanding the importance of the device and/ or method used, and (2) hands-on training in the operation of the device. Service providers should consider significant others in the AAC user’s life to a greater degree in assessment and intervention (American Speech-LanguageHearing Association, 1990; Huer & Lloyd, 1990). In a study by Light et al. (1992) three adults who served as facilitators to persons with disabilities were studied. The results indicated that after approximately four hours of training, the caregivers were able to use new interaction strategies, modify their turntaking, and initiate patterns of the dyads, resulting in more evenly balanced communication between the facilitator and the AAC user. Supervision and support are also important to ensure that caregivers effectively apply their knowledge and skills to different environments (Schepis & Reid, 2003). Staff ’s disregard of communication actions with individuals exhibiting severe mental retardation may reflect “a tendency which re10 MCNAIR JOURNAL • MIDDLE TENNESSEE STATE UNIVERSITY • SUMMER 2005 sults, in part, from low expectations regarding communicative abilities and a lack of training on how to interpret communicative acts” (Schepis & Reid, 2003, p. 61). Collier and Blackstien-Adler (1998) used information-based seminars along with peer coaching throughout joint client service with two agencies. The training was aimed to establish AAC knowledge and clinical competency. The results of the pretest indicated “average” scores to post-test scores of “above average” for each agency. They concluded that a holistic approach to developing new specialty AAC services should address the transdisciplinary training needs of the staff and the coupling of seminars and peer coaching via joint client services in order to effectively and efficiently develop specialized AAC services (Collier & Blackstien-Adler, 1998). Several authors have studied attitudes toward people who use AAC (Gorenflo & Gorenflo, 1991; Lasker & Bedrosian, 2000; Light et al., 1992; Schepis & Reid, 2003; Soto, 1997; and Richer, Ball, Beukelman, Lasker, & Ullman, 2003). However, only three of these studies examined the attitudes of human resources staff (e.g., teachers and caregivers) with respect to people with severe disabilities (Lasker & Bedrosian, 2000; Schepis & Reid, 2003; Soto, 1997). Gorenflo and Gorenflo (1991) found that to increase communicative interactions between nonspeaking and ablebodied persons, known as the participation model, information about the person’s physical status, intelligence, academic achievement, and social activities would be needed. Lasker and Bedrosian (2000) asserted that the partner’s acceptance of the user’s AAC is directly related to the individuals who rely on these methods of communications. AAC users rely on their communication partners more than those without disabilities. If their partners are uncomfortable with the form of communication, then the communicative interaction will not be successful (Richer et al., 2003). Communication partners may require instruction to support the communicative interactions of people using AAC systems (Light et al., 1992). The AAC user’s social support system should be informed by the communicative intent of the message. Specifically, the social support system must adequately incorporate the operations and applications of the device across a variety of settings in the client’s real life (Schepis & Reid, 2003). AAC use for adults with mental retardation can be an effective method of communication intervention. However, as cited by Lasker and Bedrosian (2000) caregivers’ acceptance of the AAC device will directly impact the use of the device by the individual. Also, Schepis and Reid (2003) found that staff ’s disregard of communication interaction with the client may result in low expectations of the client. Attitude is defined by Oppenheim (1966) as “a state of readiness, a tendency to act or react in a certain manner when confronted with certain stimuli” (p. 105). Gorenflo and Gorenflo (1991) described three components of attitude: the cognitive component, the affective component and the behavioral component. “The cognitive component consists of the beliefs about the attitude objects; the affective component consists of the emotional feelings connected with the beliefs; and the behavioral tendency is the readiness to respond in a particular way” (Oppenheim, 1966, p. 19). Self-efficacy was originally defined by Bandura in 1977 as a belief in one’s capabilities or skills to bring about desired outcomes. The purpose of this investigation is to examine (1) caregivers’ attitudes toward AAC used by adults with cognitive impairments in community living settings; (2) caregivers’ self-efficacy to understand the AAC device and help their clients communicate; and (c) staff ’s training on the client’s AAC intervention. The hypothesis to be tested is that with increased training of the client’s communication plan, caregivers of adults with cognitive impairments will improve in attitude and self-efficacy. Thus, the study is expected to help facilitate caregiver training and enhance the communication of adults with mental retardation.