Working with communication partners is key for any AAC intervention program to succeed. In Ogletree's presentation, he provided real-world illustrations of how to engage stakeholders actively in assessment and intervention, and discussed a comprehensive model of care-one that takes into account the child, the stakeholders and the contexts in which they live.
Barbaralyn Harden: In a clinic setting where billing matters, can you speak to what insurers are likely to cover in terms of partner training, or must partner training fall within a direct intervention session with the child?
Billy Ogletree: Wow, that is a great question. I think if the provider is involved in the training it is likely that things could be covered. That said, I come from a university clinic that has adjusted fees and sliding scales. My general thought is that co-treatment would be critical to payment by third parties, but I'm interested in the thoughts of others.
Vicki Turner: What has been your experience and success with telepractice and other alternative delivery methods, such as remote, Skype, etc.?
Ogletree: I'm just getting into this now. I have a proposal under review that would use partners via telepractice. I think it is the way of the future, especially in rural areas like mine.
Claudia Phillips: Bill, thanks for your stakeholders sessions. You mentioned an AAC intervention frame of mind where traditionally SLPs "hold the cards." I find that it has been a challenge for me in some work environments to release that territorial control. I felt the SLPs should lead the team in communication intervention strategies. A few years ago, I changed some of my mindset, and now I feel the interventions are much more effective [that is, being open to ideas across the rehabilitation professionals' disciplines].
Ogletree: You are moving in the right direction. Remember, in the presentation I stated that we are not trained to release roles and authority. This makes it difficult to let go, especially in AAC where we are traditional leaders. If we can let go a little, the world really opens up. I've gotten some of my best ideas in treatment from partners on my team.
Ogletree: I have a question for all of you. How many of you are using a formal training paradigm like the one described in the talk? I see one of the authors of that is with us.
Phillips: I plan to use a more formal training paradigm because I feel it will keep me structured and on track, a necessity when having large numbers on your rehabilitation caseload, whether it be in school or clinical environments.
Ogletree: Claudia, that is great. Can I suggest that you look at training suggestions provided by Schepis and Reid? They have done some nice work training partners, especially para staff.
Deborah Dixon: Are there cultural issues to consider when training AAC partners?
Ogletree: Absolutely. We live in such a diverse world, and that will not change. I have found that it's critical to get to know partners, to earn their trust, to learn their preferences about practice. This has really assisted me as I've tried to release my control on intervention. The more I know, appreciate and honor about my partners, the more effective my treatment will be.
Cathy Binger: I really appreciated your discussion regarding SLPs needing to re-conceptualize what we think of as "treatment." More and more, we are seeing that as the SLP's role changes (for example, moving to more of a "consultative" role in the schools), partner instruction becomes ever more crucial. You mentioned the need for a focus on this in preservice training in your talk. Could you discuss that a bit more, and what ideas you have for what that might look like?
Ogletree: I see scope of practice just getting larger and larger. That is a little scary and can be overwhelming if we hold on tightly to old service delivery models. I have been involved in preservice for SLPs in the area of severe disabilities. We have created course sequences as a part of a grant here at Western Carolina. In fact, several of our courses have peer and partner training components. I think this is the wave of the future. The problem is that there are only so many hours in a graduate program. I guess that is where alternate delivery like this comes into play.
Kim Leach: Loved the case study on Timmy, and the changes that came about using the guidance from Kent-Walsh & McNaughton. Do you use it with partners who happen to be trained professionals, and do you find some resistance? Or resistance from others to the idea of "sharing the responsibility" of the AAC with partners?
Ogletree: Kim, there is always the possibility of resistance. I have found that success is all tied up in your effort to build the relationships up front. You have to sincerely work to involve others-stakeholders-in treatment processes. Take their perspectives. See it from their eyes. As you do, they buy in and the "this is mine, and that is yours" goes by the wayside.
Amanda Gleissner: On one of your slides it stated recommended practice for ASDs included 25 hours a week of active engagement ... did you mean to include all types of support services?
Ogletree: This was directed at recommendations for kids with ASDs. You'll remember that is where I focused my case example. Recommended practice now says that 25 hours per week of engaged opportunities are needed to effect the change we want to see in kids. That is overwhelming. But what about extending services to others, giving them the control in treatment? That is what I did with Timmy and it worked. He took off not because of what I did, but because of what we all did, and did consistently.
Ann McCormick: Could you provide more information regarding the list of "exchange tips" and how it was used?
Ogletree: Great question, Ann. I knew that Timmy's mom was carrying a big load. She had another child, work and little help. Although she attended sessions, she needed help remembering our cueing sequence and ways to create exchange opportunities. The exchange tips were simply a bit of a cheat sheet for her and others. This idea probably came from the severe disabilities literature and the idea of gesture dictionaries. You know, a list of ideas. It took the pressure off mom and was only used initially in transition.
Marta McAulay: As an SLP in a school setting, I often find that there can be a discrepancy between various stakeholders, such as the school team and the family. Can you speak about strategies/tools that you have used to help these two teams move to working collaboratively?
Ogletree: Again, it is all in the relationships. I've found it helpful to develop team agreement statements. To say that we will agree to put the kid and family first, for example. To listen to each other, to respect differences. That said, there are times when there is disagreement. Open communication and putting the child and family first usually helps folks move to a unified voice where possible. I've found that to be the case.
Thomas Johnson: In your eight-step program with training, how important is the pre-test stage? And how do you conduct the pre-test section?
Ogletree: Wow, if Jennifer [Kent-Walsh] is still on she may want that one. I think that she and David [McNaughton] may have used this as a part of their research. They obviously use it as a baseline of partner knowledge. I did not use it because the mom, in Tim's case, would have been put off by it, I think. Jennifer?
Jennifer Kent-Walsh: We have found that step to be very important. It provides an opportunity to step back and focus on the communication of the child and discuss specifics of what we would like to see change over time. We can then switch to what we might focus on with the partner to make that happen. Of course, the later comparison between before- and after-instruction then helps in securing the commitment to long-term implementation of supportive partner strategies.
Ogletree: Thanks, Jennifer. By the way, I hope you guys attending take the time to follow Jennifer and Cathy's work on partners. It is very solid. (See "Communication Takes Two," The ASHA Leader, Dec. 18, 2012.)
Jeri Jones: I have seen instances where the parent-child fit is challenging-different communication styles, different emotional make-up, different sensory systems ... How does this influence your intervention?
Ogletree: I assume you mean that the parent is not connecting with the child. I have certainly seen this as well. I think it is important in cases such as this to spend some up-front time allowing the parent or stakeholder to get comfortable, and to observe some alternative interaction styles with their child. As they do, it has been my observation that they are more open to the possibility of partnering and they contribute more to the process.
Mark Turek: Recently, I heard that the number of Asian immigrants has surpassed that of Hispanic immigrants in the United States. With this in mind, can you speak to how we might effectively become more culturally competent when trying to establish the bidirectionality of family involvement when we are being faced with the influx of so many different cultures into our schools? How do we bridge these cultural differences to help optimize success for all of our students?
Ogletree: I ran into this a bit when I was in Kansas City and the Medical Center at Kansas University. We had increasing situations where we were not knowledgeable about culture or individual differences. One way we addressed it is with partners from those various cultures. We included stakeholders in our diagnostic or treatment processes that had experiences we did not. It built relationships and allowed us to practice more effectively.
Diana Osenga-Manolovits: My mind is going a hundred miles a minute to try to figure out how to begin implementing this with several children, educators, SLPs, support personnel, parents, other communication partners and stakeholders. I wish that I could share all this information with them individually, but that does not seem possible. Do you have any suggestions on where group instruction is possible and where individual is critical?
Ogletree: I think that there is a place for group instruction with partners. I have used it with creating response consistency from partners responding to guys with very severe disabilities. I think you need a group that has some common experiences and ambitions. My efforts were very effective with paras who were really invested in learning about how to interact with these little guys. I think group instruction may be useful with general ideas as well.
Harden: There is a lot of systemic resistance to what we may view as a positive shift to a more consultative role or partner training role in both schools where families often perceive the SLP as the expert and in the clinical setting where reimbursement is based on the "expert's" direct intervention. This is a systemic issue. Any tips on advocacy with school administrators and insurers to help make the shift that is so important?
Ogletree: Well, try the one about 25 hours of intervention for kids on the spectrum. That will shake up any school administrator and should make your point that effective intervention is about more than you can do. It is also about more that you see. Remember in the talk I mention all the systems that act on families. I think administrators can make the shift if we do a good job of illustrating this. Unfortunately, we often sell the expert model.
Johnson: This is a really good talk! In my partner-assisted treatment with students with ASDs using assistive technology there is sometimes a disconnect with parents who demand a lot of intervention but really resist being involved themselves. We train together and then follow-through with these parents as stakeholders is slim. Any thoughts or suggestions here?
Ogletree: Thomas, you need to accept them where they are. Start with that, at least, especially as you remember that lots of things may be impacting their lives. Over time and through relationship-building, my guess is that they can move to another place-one of more involvement. It might also help for them to see how stakeholder involvement helped others. My guess is that some of your other parents might share, or be a part of, one of those groups we mentioned.
Martha Leary: Billy, thank you for your focus on ASD and the challenges of AAC. What is your favorite story of AAC partnering with a person with autism?
Ogletree: Wow, I have a few. I guess there have been several where the partners were the guys on the spectrum helping others on the spectrum. We do a social skills group here, and several times guys with ASD are the ones assisting others-especially when they have a skill set that others do not.
Johnson: On the pre-test, do you use an informal approach or a more formal approach?
Ogletree: Thomas, I guess it depends on your purposes. If you are gathering data for a research project something controlled is needed. If not, I'd go with the informal approach. Let me end with a big thanks to all of you for allowing me to join you.