Imagine a classroom assistant asking multiple questions of a preschooler with a communication disorder, without pausing or expecting him to communicate. Or consider a client's spouse who gives complex instructions to his wife, despite her significant comprehension deficit.
If you have witnessed situations like these, you might wonder why it is so hard for communication partners—whether family members, educators, health care professionals, or peers—to provide support for someone with complex communication needs.
Part of the issue may be that the techniques we use daily—modeling, expectant delays, prompting hierarchies, and so forth—can become second nature to us. However, we forget how hard we worked to learn to acquire clinical skills, and how much guidance we had from our mentors in learning to use new techniques with clients. Perhaps, then, it is little wonder so many of our suggestions to communication partners go unheeded. Just as clinicians need plenty of guided practice to learn new techniques, so do communication partners.
Teaching Communication Partners
In recognition of this need, various clinicians and researchers have developed programs to provide communication partner instruction. Some partner instruction programs, such as the Hanen Centre Programs, take a broad approach to instruction and involve instruction implemented over a period of several weeks or months. Using this type of partner instruction for children with language disorders, and specific diagnoses such as autism spectrum disorders, has resulted in changes in partner communication and children's communication patterns (e.g., Girolametto, 1988; Girolametto, Sussman, McConachie, Randle, & Couteur, 2005; Tannock, Girolametto, & Siegel, 1992; Weitzman, 2007).
In our own research with children who have complex communication needs, we have focused initial partner instruction more narrowly. Our individualized instruction programs aim to have partners and clients experience significant success within one-and-a-half to five hours of instruction. The research-based Improving Partner Applications for Augmentative Communication Techniques (ImPAACT) program has eight steps, and has been documented to be effective in addressing a range of communication and language goals for children using AAC by working with a variety of communication partners, including educators, parents, and peers (e.g., Binger, Berens, Kent-Walsh, & Hickman, 2008; Binger, Kent-Walsh, Berens, Del Campo, & Rivera, 2008; Binger, Kent-Walsh, Ewing, & Taylor, 2010; Kent-Walsh, Binger, & Hasham, 2010).
Our experience with this program has taught us that one aspect of partner instruction—selecting techniques to teach partners—presents particular challenges for clinicians. Although what you want partners to do may seem obvious (for example, ask more open-ended questions or stop providing so many direct verbal prompts), there is much more to the process of selecting partner techniques.
In reports from clinicians on their experiences in implementing the ImPAACT program, a common theme emerged in relation to the challenges they have faced. They were able to follow the eight-step program with ease—that is, the ImPAACT program provided them with the necessary information to know how to conduct partner instruction—but later reflection revealed they may not have given sufficient consideration to exactly what they would target with particular communication partners and in what sequence. Common challenges reported by clinicians when describing their work with communication partners include:
- Focusing on what is "wrong" with the partner instead of improving client behaviors.
- Trying to change too many partner behaviors at once.
- Trying to change too many client behaviors at once.
- Trying to change client and/or partner behaviors in too many settings or situations at once.
- Failing to link changes in partner behaviors with identifiable, measureable changes in the client.
To address these issues, we have developed four guidelines to assist with partner skill selection prior to the implementation of a partner instruction program. These guidelines are presented for consideration with child and adult clients.
1. Identify partner behaviors that result in desired client skills and are clearly linked to client outcomes.
Given the co-construction of meaning inherent to communicative interactions, partners need to be considered when selecting client skills, and vice versa. Sometimes you know exactly what communication behaviors to target for the client, and you know exactly which partner behaviors will help elicit those behaviors (see examples in the table [PDF]).
In many other cases, however, the inspiration for wanting to change the partner's behavior may come from observing the partner using less-than-ideal strategies, such as asking too many questions or prompting too often. But even in these situations, it is critical to focus instruction on changing client outcomes, not partner behaviors. Focusing on client changes helps maintain a positive, team-based approach to instructional sessions. The clinician might, for example, say "Let's figure out how to help (NAME) together," rather than focusing on what the partner is doing "wrong."
If your starting point is undesirable partner behaviors, ask yourself the following questions:
- What is the partner doing—or not doing—that fails to facilitate effective communication?
- What exactly could the partner do instead to be more facilitative?
- What exact client behaviors would result from these changes?
The answers to these questions may seem obvious at first, but clinicians struggle the most in this area. For example, you might answer these questions by saying, "The classroom assistant is prompting the student too much. She needs to talk less so the student has a chance to say something," or "The husband's instructions are too complex and his wife doesn't understand him. The husband needs to consider his wife's current communication level."
Although these observations may be accurate, the partner behaviors and client outcomes are too vague to be truly helpful for most partners—that is, asking someone to "talk less" or "use simpler instructions" is unlikely to result in permanent changes in how the partner interacts. These suggestions may seem simple to us, but most partners require a more pointed approach—and the first step is to define carefully and systematically the desired partner techniques and client skills.
Before you decide what you want the partner to do differently, explore this issue in depth by brainstorming a list of all partner techniques that might be helpful. For example, for the assistant who prompts too much, the list of desirable partner behaviors might include providing fewer prompts overall, providing fewer direct prompts, increasing the number of natural cues, asking more open-ended questions, providing expectant delays after each cue, modeling target responses, and responding contingently to each partner turn.
For the husband, desirable behaviors might include providing one direction at a time, using simple and concrete sentences, supplementing instructions with visual supports (such as pictures), modeling the behaviors he wants to elicit, and pausing for several seconds after each instruction.
Use the list of possible partner techniques to make a list of client skills that may result from their implementation. This includes, of course, documented goals for intervention. For example, the preschooler might increase his turn-taking rate, use more diverse vocabulary, construct longer messages (three to four words), construct more grammatically complete messages, ask more questions, etc. For the husband working with his wife, goals may focus on various aspects of direction-following, such as following one-step concrete directions with verbal cues, visual cues, and models.
2. Select well-defined, easily identifiable, and easily quantifiable client skills and partner techniques that change quickly.
Using the partner technique list and client skill list, maximize the chances for success by selecting one salient technique to be implemented in one well-defined context. It is tempting to do more, but keeping a narrow focus will increase chances for success and reduce the communication partner's cognitive load. Remember, partners will be practicing new techniques while trying to keep track of the client's performance. In our experience, asking partners to do too much, too fast contributes to failed partner instruction—so keep it simple.
In addition, select a client skill that meets the following criteria:
- The skill is stimulable—that is, the client can demonstrate this skill when provided with the proper supports.
- The skill is readily identifiable—partners can recognize it when they see it.
- The skill is easily measurable—partners can see the client's progress.
The chart [PDF] contains examples of highly specific, identifiable, and measurable skills. The objectives are narrowly defined and easily measurable.
After you have selected a client skill, decide exactly what to teach the partner to help achieve it. When taking a focused approach to partner instruction, it is crucial to select partner techniques that:
- Are narrow and well-defined.
- Eliminate ineffective partner behaviors.
- Can be taught quickly to the partner.
- Change the client's outcomes quickly.
- Are easily identifiable and measurable.
- Can be used initially within one or two very specific contexts.
Broadly speaking, you can take one of two approaches when selecting communication partner techniques. One approach is to select one or perhaps two specific techniques, such as teaching the partner to ask one question at a time and to then provide an expectant delay. Another approach is to teach the partner how to use a strategy—a series of predictable steps, such as the use of a cueing hierarchy. Because evidence indicates both approaches can be effective in improving client language and communication skills, your choice should depend on what works best for achieving the client's goal.
3. Practice the selected partner technique with the client.
The next step is to validate carefully your selection of partner technique and client skill by completing several trials with the client before beginning work with the partner. Simulate what you would like the partner to do as closely as possible—the setting, materials, partner techniques, etc.—so you can streamline your instruction, anticipate issues that may arise, and prevent frustration later on. This step also helps clinicians determine why past attempts at partner instruction may have been unsuccessful; that is, practicing the precise partner techniques with the client forces clinicians to define exactly when to use the technique and when not to. This instruction may not be nearly as straightforward as you initially thought.
For example, you've decided to teach the assistant how to use a defined cueing hierarchy to elicit communicative turns from the child during a 10-minute story. When you practice using this cueing hierarchy with the child, it becomes clear that you need to define exactly when to use the first cue (for example, each time you turn the page), how long the expectant delays should be, when to accept a turn from the child, etc. It also becomes clear that the child's performance varies depending on the book, so you carefully select the most motivating stories for the assistant to use.
For another example, assume you've decided to teach Mr. C. how to provide simple verbal instruction for his wife, followed by an expectant delay. During your practice sessions with Mrs. C., you realize you need to specify what a "concrete, one-step verbal prompt" consists of—for example, "Mrs. C., I want you to lift your left leg without bending your knee," rather than, "Lift this leg"—and that Mrs. C. requires an exceptionally long expectant delay (at least 10 seconds) to process even very brief instructions.
4. Start small. After you achieve initial success, expand.
It is better to achieve success within a brief, narrowly defined context and then expand, than to try to do too much at once and achieve no success at all. With initial gains, it is relatively easy to go further. The client and partner gain new skills on which you can build, and the process leaves everyone feeling good about their achievements and willing to do more.
Expanding contexts is probably the easiest way to promote generalization. For example, the classroom assistant can move on to using the same previously implemented cueing hierarchy with other types of storybooks or in other kinds of contexts, such as craft or circle-time activities. When appropriate, partner techniques might also be expanded—for example, Mr. C. might learn to provide a visual model for his wife when he provides a new and unfamiliar instruction.
Regardless of how you choose to expand, for most communication partners it is critical to continue to define exactly where and when they should use techniques they have learned. Expecting them to begin using newly mastered techniques appropriately throughout the day in other contexts is, for most partners, too much to assume—and such an expectation can lead to frustration.
After you have carefully defined the partner techniques and client skills you will target (what you will target and why you will do so), you should take an evidence-based approach to how you will conduct partner instruction. The need for a systematic approach to conducting partner instruction in augmentative and alternative communication that incorporates principles of active learning has been well documented (e.g., Kent-Walsh & McNaughton, 2005; Thiessen, Horn, Beukelman, & Wallace, 2011). Our own ImPAACT Program enables partners to engage as active participants in instruction, and to practice new techniques through verbal rehearsal and role-play before tackling more demanding and distracting real-world settings (Kent-Walsh, Binger, & Malani, 2010).
Our findings indicate that using this program yields successful communication outcomes for partners and clients after only one-and-a-half to five hours of individualized instruction—an efficient and viable approach, when compared with the total number of unproductive hours that may be spent on less formal approaches. Regardless of the protocol you choose to conduct partner instruction, taking the time to select partner techniques and client skills carefully prior to partner instruction will enhance everyone's chance for success.