For people with little or no speech, literacy is a critical skill that opens up much more of the world, according to Jessica Caron, associate professor of communication sciences and disorders at Penn State. Through reading and writing, an individual who cannot engage in conversation without assistance has access to a full range of communication options and maximum freedom of expression - but learning literacy can prove challenging.
A new study from an interdisciplinary team of researchers, led by Caron, examined the effectiveness of adapted literacy instruction for a child with cerebral palsy who uses a high-tech eye-gaze augmentative and alternative communication (AAC) device to communicate. Their findings, published in Augmentative and Alternative Communication, suggest that people with movement and language difficulties may be able to learn far more literacy skills than previously thought.
AAC is any strategy or tool used to supplement speech, from pointing at pictures in a communication notebook to selecting symbols in a specialized app on an electronic tablet. For individuals who have little or no speech, AAC is an important tool used to support communication across a range of people and contexts, Caron said.
Until now, there was little research about the acquisition of letter-sound correspondences (LSCs) - the understanding that sounds are associated with letters of the written language that makes up speech - for individuals with cerebral palsy who use high-tech AAC, Caron said. This is the first study to explore early literacy skill instruction for people with motor impairments who use AAC through eye gazing rather than through pointing or touching.
"Individuals who use or need AAC are often excluded from early phonics-based instruction because most of these learning opportunities currently require speech," Caron said. "When working on letter-sounds, the teacher may hold up a letter card and the class says the sound out loud. With some task adaptations, all learners, including those with communication and motor skill challenges, can participate in these critical early literacy tasks."
The adapted intervention used in this study focused on the acquisition of seven LSCs using high-tech eye-gaze AAC.
"This skill can be challenging for individuals who can't use speech to communicate or even deemed impossible when service providers don't know how to make the necessary task adaptations," Caron said. "Their challenges with speech often result in a lack of access to appropriate instruction, resulting in them never learning how to read. In more than 90% of cases, that is what happens to students who have the most severe speech and language disorders."
This study focused on the literacy instruction of a four-year-old boy who used a high-tech eye-gaze AAC device. Before the study, the child was limited to two speech approximations - simplified or altered productions of words to make them easier to articulate - for "yes" and "no," and six idiosyncratic sign approximations - variations from traditional sign language specific to an individual - for "bite," "drink," "iPad," "thank you," "sorry" and "potty."
Prior to participating in this study, the child knew three letter sounds - a, m and p - from participation in a previous research study but had received no formal literacy instruction.
Based on results from a screening assessment, the researchers selected seven LSCs from letter sounds the child had not previously acquired. The instruction included explicit trials with the target letter sound and two "extension activities," an LSC image book and a file folder sorting game. These were designed to provide additional practice in a more interactive and motivating way, given the young age of the participant, Caron said.
To instruct the child on each letter, his AAC device was programmed with grids consisting of four different letters. The instructor would orally present the corresponding letter sound and record the child's response using dwell selection - the amount of time an eye gaze is held on a specific area of interest.
Each letter was taught individually, and a new letter would be introduced when 80% accuracy for the previous letter was demonstrated.
"Many individuals who have minimal or no speech could learn to read if they were provided the opportunity and the right evidence-based supports," Caron said. "Our results with this pilot study validate that hypothesis."
Upon completion of the study, the child demonstrated mastery of all the LSCs presented during instruction. For each LSC presented, he showed an increase in the number of correct responses when identifying the LSCs from the original assessment conducted prior to the beginning of the study.
In the pre-study assessment, the child identified the correct response roughly 15% of the time. After the 15-week study was complete, he identified the correct response anywhere from 80% to 100% of the time.
"Prior to participating in this study, the child was saying single words with his AAC device and not typing at all," Caron said. "This was just the starting point for him. By the end of his first school year, he was able to use his communication device to write simple sentences like, 'I go nap.' Without literacy, a child with his abilities would never be able to express himself the way he can with proper instruction. With continued instruction, there is no telling how much independence and self-expression he will be capable of by the time he completes high school."
The results of this study led Caron and her colleagues to develop an online training program to help support providers implement this kind of instruction. The online training is designed to teach speech-language pathologists, teachers and pre-service speech-language pathologists to provide quality adapted literacy instruction.
Caron and her team are currently conducting a larger-scale research project that includes the development of an intervention of many early phonics skills beyond letter sounds and will implement a 30-minute phonics block in schools for learners who use AAC.
"Everyone has the fundamental right to have opportunities to learn to read," Caron said. "Our vision is that all children, including those who use or need AAC, are provided with daily literacy opportunities that include access to phonics instruction, and we've seen that when provided with adapted tasks and quality daily instruction, these students are learning to read!"
Additional authors include Nicole Ryan, speech-language pathologist currently working in public schools who earned her master's degree in communication sciences and disorders at Penn State; Salena Babb, research coordinator for the AAC and Literacy Lab at Penn State; Christine Holyfield, associate professor of communication sciences and disorders at the University of Arkansas; and Meghan O'Brien, speech-language pathologist and clinical coordinator in the Department of Otolaryngology and Communication Enhancement at Boston Children's Hospital.
The American Speech-Language-Hearing Foundation Researcher-Practitioner Collaboration Grant and The Pennsylvania State University Mark T. Greenberg Endowment supported this work. Nicole Ryan was funded through the Office of Special Education Programs Grant - a U.S. Department of Education personnel preparation grant.
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