JCPSLP Vol 21 No 3 2019

Journal of Clinical Practice in Speech-Language Pathology Journal of Clinical ractic i Spe ch-L l

Volume 13 , Number 1 2011 Volume 21 , Number 3 2019

Multimodal communication

In this issue: Multimodality in augmentative and alternative c ommunication Improving the ideas behind multimodal communication Clinical-decision m aking for communication intervention Capacity building for families with augmentative and alternative communicationservices Ethical considerationsfor AAC novice Top 10 resources for multimodal communication

Multimodal

communicatio

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Multimodal communication

From the editor Jae-Hyun Kim

Contents

W elcome to the final issue of 2019. In this issue, we focus on multimodal communication. We begin with Professor Teresa Iacono’s article on the evolution of how multimodality has been considered in the field of augmentative and alterative communication in speech-language pathology clinical practice. This article is followed by a considered and critical take on multimodal communication by Scott Barnes. Together these two articles provide invaluable insights of the past, the present and the future of multimodal communication as it is contextualised within speech-language pathology clinical practice. Many of our readers will be familiar with these two authors. I am grateful for their willingness to share their knowledge with us. The third article is by Andy Smidt who provides a practical guide to developing holistic, ecologically valid intervention approaches for people with

125 From the editor 126 An exploration of

multimodality in augmentative and alternative communication – Teresa Iacono

131 Improving the ideas behind multimodal communication – Scott Barnes 135 TEAM – A taxonomy of clinical decision-making for communication intervention in people with severe intellectual disability including AAC – Andy Smidt 143 Capacity building outcomes of Kids Chat 2 You: A state-wide service providing families with augmentative and alternative communication services

intellectual disabilities. Although the article is written for students and early career speech- language pathologists, even experienced speech-language pathologists will find the taxonomy presented in this article useful. The fourth article is presented by speech-language pathologists at Scope and La Trobe University. They report on a community capacity building project, Kids Chat 2 You. Our clinical practice is becoming increasingly community-based and it is great to get insights into a community capacity-building program from experienced speech-language pathologists. In the fifth article, speech-language pathologists at Bendigo Health report on the prevalence of patients requiring assistance to communicate their health care needs. I thank the authors for bringing to our attention once again that communication is an essential component in the provision of quality health care and that speech-language pathologists have a unique role in ensuring and facilitating effective communication for our clients. In this issue, we also have an opportunity to present other important areas of speech- language pathology clinical practice. The first of these articles is on complex feeding decisions, contributed by our colleagues in Queensland. You may recognise the lead author, Maria Schwarz, as the recipient of the Journal of Clinical Practice in Speech-Language Pathology Editor’s Award. This is a great article describing and providing a critical look at the current practice patterns involving complex feeding decisions. The last of our research articles in this issue is on further predictions of Lidcombe Program treatment time. A collaboration between the speech-language pathologists at Stuttering Unit in Sydney and University of Technology Sydney, this article reports on variables involved in influencing Lidcombe Program treatment time. This will be a very interesting article for those who are working with children who stutter. Our issue would not be complete without an ethical conversation. This issue’s “Ethical conversation” is about novice speech-language pathologists working in alternative and augmentative communication. “Around the journals” section reviews a recent systematic review on the barriers and facilitators to the provision and use of low-tech and unaided alternative and augmentative communication systems. “Resource review” looks at a web resource focused on support and implementation of alternative and augmentative communication. In our issue’s final section on “Top 10 resources”, Harmony Turnbull shares with us the ways to support accessible communication for people of all ages. This issue would not have been possible without the authors and I thank them sincerely. As always, and particularly for this issue, I am grateful for the support provided by our publication manager Rebecca Faltyn and our production team Carla Taines and Bruce Godden.

– Hilary Johnson, Marion Van Nierop, Alison Heppell, Jasmin Prewett, and Teresa Iacono

149 Prevalence of patients requiring assistance to

communicate their health care needs – Jacqui McCrabb, Tracy Sheldrick, and Jemma Tulloch

154 A retrospective cohort study of complex feeding decisions: Informing dysphagia decision- making through patient experiences – Maria Schwarz, Anne Coccetti, Elizabeth Cardell, Tanya Hirst, and Lucy Lyons

159 Further predictors of

Lidcombe Program treatment time – Verity MacMillan, Stacey Sheedy, and Mark Onslow

165 Ethical conversations: Ethical considerations for AAC novice – Alison Moorcroft, Jane Burrett, and Hannah Gutke

169 Around the journals 170 Resource review 171 Top 10 resources for

multimodal communication – Two-way multimodal communication across the lifespan – Harmony Turnbull

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Multimodal communication

An exploration of multimodality in augmentative and alternative communication Teresa Iacono

The aim of this paper was to trace the evolution of how multimodality has been considered in the field of augmentative and alternative communication (AAC) and the potential implications for clinical practice. Early reference to the notion of multimodality appeared to reflect concerns about AAC decision-making that resulted in recommendations for single modality systems and the exclusion of people from AAC interventions. Providing people with AAC, regardless of their underlying symbolic capacity, has been a reaction to the rejection of a candidacy model and the adoption of the participation model. However, a potential danger may arise from expecting individuals who are pre-intentional to acquire symbolic skills. In line with the participation model, AAC can be used appropriately for these individuals for mediating responses from people in their social environments, while providing opportunities for symbol communication. T he terms multimodality and multimodal communication have become so ubiquitous in speech-language pathology (SLP), and more broadly, communication disorders literature and practice, that there seems little reason to explore the concept. Yet the growing use of the term speaks to an ongoing evolution of the profession’s understanding of communication disorders and scope of practice, and the role of augmentative and alternative communication (AAC) in supporting the Classification of Functioning, Disability and Health (World Health Organization, 2001), SLP has extended its focus over the years from reducing impairment, such as through developing or restoring speech and language, to improving function and participation, and considering contextual environmental and personal factors in assessment, goal- setting and intervention practices (Speech Pathology Australia, 2017). This focus is particularly evident in the field of AAC, in which the notion of communication in any and communication of individuals with varied needs. As a profession influenced by the International

all modalities that are available to the individual has been embraced. Hence, in AAC, multimodal has come to include all forms of conventional communication: speech, signs, well-recognised gestures, graphic symbols, and traditional orthography (Speech Pathology Australia, 2012). It has also come to encompass informal and less conventional forms; examples are idiosyncratic gestures and behaviours, facial expression, vocalisations, and even problem behaviours (Speech Pathology Australia, 2012). And of course, there is overlap across formal and informal modalities. Deaf sign language across countries, including Auslan, is a case in point in that facial expression and directionality add linguistic information to the handshape, location and movement of individual signs (Musselwhite & Louis, 1988). Despite widespread and perhaps intuitive understanding of what multimodality means and comprises, SLP appears to have embraced the concept and practice in only relatively recent times. Multimodal communication as a term did not appear in the 2015 revised SLP scope of practice (Speech Pathology Australia, 2015). It did appear in the revised 2017 version of the document identifying competencies and standards expected of people entering the profession: that is, entry-level Competency Based Occupational Standards (Speech Pathology Australia, 2017). This change may have arisen because of the inclusion of AAC as a form of multimodal communication in a clinical guideline developed to assist SLPs to use evidence-based approaches to design and implement AAC for clients with complex communication needs (Speech Pathology Australia, 2012). The question is: why did this change come about? Exploration of the evolution of multimodal concepts within the field of AAC and how it has come to inform practice, perhaps, at times with some confusion and misunderstanding, may offer some insights. The aims here were to trace how understanding multimodal communication has evolved in the field of AAC and to address potential misperceptions that could have implications for clinical practice. Multimodal as more than one type of AAC Within the AAC literature, the term multimodal appeared in early discussions and research into the benefits of using more than one type of AAC in an effort to counter practices that appeared to favour single systems. Survey research conducted across United Kingdom (UK) schools for children with severe intellectual and physical disability, and autism,

KEYWORDS AUGMENTATIVE AND ALTERNATIVE COMMUNICATION CLINICAL DECISION- MAKING COMPLEX COMMUNICATION NEEDS MULTIMODAL THIS ARTICLE HAS BEEN PEER- REVIEWED

Teresa Iacono

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children with severe intellectual disability. With colleagues, I extended this line of research into the benefits of multimodal AAC to include aided symbols in scaffolding language learning by comparing sign+speech with sign+speech+aid (the latter a speech generating device) for children with Down syndrome or developmental delays (Iacono & Duncum, 1995; Iacono, Mirenda, & Beukelman, 1993). Findings indicated either greater learning in the three- compared to the two-modality condition (children with Down syndrome from respective studies) or similar learning across the conditions (one child with developmental delay in the study with Mirenda and Beukelman). These studies demonstrate that providing multimodality options allows children to choose those that best suit their learning strengths and/or modality preferences. to support a person’s communication functioning and development. In one such case study, Garrett, Beukelman, and Low-Morrow (1989) documented the decision-making process in creating a comprehensive and multimodal AAC system for Mike, a 74-year-old man with Broca’s aphasia. The system comprised an alphabet card, writing paper and word dictionary, which were chosen on the basis of his residual skills and preferences, and he was encouraged to use his existing (if often unintelligible) natural speech. A further example is provided by Light, Beesley, and Collier (1988), who documented a 3-year process of providing an adolescent with a head injury with AAC that would meet her current and future needs, while also complementing and facilitating therapy targeting her speech. These case studies demonstrated the multimodal nature of communication. A contrasting, but not unrelated, view of multimodality comes from authors who have referred to it in terms of asymmetry across input and output modes, such as occurs when a person uses AAC for expression, but speech for comprehension when aided input is not provided or required (Martinsen & von Tetzchner, 1996). Lloyd, Loncke, and Arvidson (1999, p. 166), for example, referred to multimodality as ‘the ability and tendency of human beings to combine and integrate different information sources in message reception and message expression. The term refers to the fact that human beings tend to process information in more than one mode’ . Equating multimodal with AAC Referring to AAC as multimodal provides explicit acknowledgement that access to multiple forms of AAC addresses the varied communication needs and preferences of people with complex communication needs (see Iacono, Lyon, West, & Johnson, 2013; Trembath, Iacono, Lyon, West, & Johnson, 2013). The issue is whether all multimodal communication is AAC. Common sense would suggest not, given that communication occurs through multiple channels that combine formal (e.g., print, speech, conventional gestures) and informal (e.g., vocalisations, facial expressions) modes, but only relatively few rely on AAC systems. Yet, there does seem to be evidence in the literature of including as AAC all forms of extant communication (intentional or unintentional) used by a person with complex communication needs. Cress and Marvin (2003, p. 256), for example, stated “Teaching Combining AAC with extant communication modalities AAC research has a rich history of providing detailed case studies that have demonstrated the complex nature of AAC clinical practice and need to consider all available modalities

reported by Kiernan, Reid, and Jones (1982), for example, demonstrated a tendency for schools to adopt either signs (Makaton or Paget Gorman Sign System) or graphic symbol (e.g. Bliss, Rebus) systems, with few introducing both at the school level, let alone for individual students. These choices were often based on recommendations by the school speech therapists. They prescribed AAC systems for a school rather than for individual students (Kiernan et al., 1982), thereby promoting a belief that all students in the same school should either sign or point to graphic symbols on aids (most often communication boards or books). The idea that only one AAC system could meet all of an individual’s communication needs in the absence of functional speech, let alone those of all students in a school, appeared to reflect a concern in the AAC literature. Baumgart, Johnson, and Helmstetter (1990), for example, argued against a tendency to treat AAC decision-making as a process that should result in identifying one AAC system to meet a person’s communication needs. Rather than referring to multimodal systems, they used pluralism to mean “the use of more than one type of system” (p. 8). Similarly, Bloomberg (1991) provided guidance to parents and teachers in choosing an appropriate AAC system for a child who had failed to develop speech, listing the various features and considerations of unaided and aided systems. She stated that “Use of an unaided system does not rule out use of an aided system and vice versa” (p. 38). As the range of AAC systems expanded, particularly with technological advances that resulted in increasingly sophisticated devices, but often with large price tags, the decision-making process in AAC became more complex (Musselwhite & Louis, 1988; Sigafoos & Iacono, 1993). Earlier decision-making guides evolved into feature matching, whereby AAC system components are selected and/or designed according to knowledge of an individual’s capabilities and preferences (Speech Pathology Australia, 2012), but the message increasingly was that no single device would meet all needs, either at one point in time or into the future (Sigafoos & Iacono, 1993). Hence, multicomponent systems (Musselwhite & Louis, 1988) and multiple communication modalities were encouraged. Other early references to the concept of multimodality in the context of AAC use include total communication and simultaneous communication . In early writings, these terms referred to the use of signs for one or more of the main content words while simultaneously speaking all words in a sentence (Kiernan et al., 1982; Konstantareas, Oxman, & Webster, 1977), a practice that continues in Key Word Sign (Speech Pathology Australia, 2012). Total communication, as a term, lost favour in the AAC field because of its specific meaning in the Deaf community and literature as an approach that was considered diametrically at odds with oral communication, whereby students were immersed in speech training without the use of signs (Geers & Moog, 1992). Early AAC studies addressed the effectiveness of simultaneous communication for young children. Konstantareas et al. (1977), for example, demonstrated the benefits of simultaneous communication (sign plus speech) in improving the receptive and expressive (imitative and spontaneous) sign vocabulary of children with complex communication needs associated with severe autism; similar findings were obtained by Kouri (1988) for children with varied aetiologies, including Down syndrome and autism. Remington and Clarke (1993) found that simultaneous communication resulted in improvements in expressive sign as well as speech comprehension for

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may hit a single switch on which is placed a graphic representation of the message “my turn,” which results in the child being given a turn in a game. In this example, the child may not have the representational understanding of the picture, but the aim may be to teach the equivalence between a consistent behaviour (hitting a switch) and a desired outcome, thereby enhancing understanding that this is the way to gain access to a game (i.e., to request a turn). Teaching basic pragmatic functions through the use of conventional forms provides the individual with the experience of power to effect a response from the environment, thereby countering experiences of learned helplessness and frustration. An early AAC text by Reichle et al. (1991) provides chapters addressing the use of symbols to teach a generalised request (e.g., graphic symbol or sign for “want”) or generalised rejection (e.g., graphic symbol or sign for “no”). Through these interventions, individuals who may be presymbolic learn basic pragmatic functions that are readily communicated and responded to, and thereby provide a means to shape behaviours towards intentionality. The next step is to provide the opportunity to expand them to symbols for specific requests and rejections, which may or may not eventuate. Implications for clinical practice Rejection of candidacy requirements in favour of the participation model, and viewing all extant behaviours as part of multimodal AAC carries the potential for symbolic systems to be introduced to individuals who may not have symbolic skills. Arguably, and as previously mentioned, this practice is appropriate if the AAC system is used to teach use of a conventional form to demonstrate basic pragmatic functions. A potential problem arises if the expectation is that the person will be able to use the symbols, regardless of the modaliy, as abstract representations, which can lead to failure of the AAC intervention (Rowland & Schweigert, 2000). In a study involving children with severe and multiple disabilities, colleagues and I argued against this practice because of the potential ‘to increase the child’s communication failures, reduce his/her attempts to communicate, and reduce the faith in the effectiveness of augmentative and alternative communication systems among care givers’ (Iacono et al.,1998, p. 112). It would seem then, that the onus is on clinicians to select goals based on their understanding of a person’s underlying competence, and to clearly articulate these to families and other support people to ensure a common understanding of the role of an AAC system and the various modalities encompassed in the intervention: for example, to expand pragmatic functions or to extend language skills. Failing to do so can create confusion about the intention of intervention and resentment towards clinicians, as was found by Edwards, Brebner, McCormack, and Macdougall (2016) in interviews of parents about what they wanted from therapists working with their children on the autism spectrum. Conclusion An early focus on multimodality in the AAC literature reflected concerns about practices that limited options for people with complex communication needs. As understanding of AAC as being multimodal by its very nature, and the benefits of providing people with varied and multiple forms of AAC grew, the profession of SLP expanded its scope of practice in relation to AAC such that

parents to adapt their responses to their children’s communication signals … can be considered AAC”. Issue can be taken with this statement in light of an accepted definition of AAC as combining communication strategies, techniques and interventions, in which formal modalities are provided through unaided and/or aided systems (Speech Pathology Australia, 2012). Hence, Cress and Marvin appear to be confusing an intervention strategy (one component) with the whole (system). On the other hand, Cress and Marvin (2003) reflected a concern in the AAC field of waiting until certain prerequisites, mostly cognitive (especially imitation, object permanence and means-end behaviour), were demonstrated or individuals failed to develop speech after prolonged speech training before being given access to AAC (Wilkinson & Hennig, 2007). This practice reflected a candidacy model, whereby individuals, regardless of age, needed to demonstrate that they were ready for AAC: that is, they had demonstrated candidacy requirements. The implementation of candidacy models left people with complex communication needs without access to a functional means of communication, and perhaps of the means by which they could demonstrate underlying communication capacity. Such capacity can be masked by multiple impairments (Iacono, Carter, & Hook, 1998; Rowland & Schweigert, 2000), learned helplessness arising when people in the social environment cannot read subtle or unconventional signals (Reichle, York, & Sigafooos, 1991), or years of failure to learn speech despite intensive intervention (Wilkinson & Hennig, 2007). Multimodal and AAC interventions for non-symbolic communicators The shift from a candidacy to a participation model, whereby assessment to determine appropriate AAC systems is conducted with individuals across ability levels (Mirenda, Iacono, & Williams, 1990), resulted in attention to interventions for children who were pre-intentional (Rowland & Schweigert, 2000) or adults who were unintentional 1 (McLean, Brady, McLean, & Behrens, 1999). These individuals have benefited from access to symbolic forms either in sign or on aids, but some have not progressed to symbolic communication. Rowland and Schweigert (2000), for example, implemented an AAC intervention in which 41 children with various severe and multiple disabilities were taught to request using tangible symbols. The children had varied outcomes: some quickly acquired the tangible symbols and then moved to more abstract forms (including speech for some), others acquired a few symbols and some, none at all. Rowland and Schweigert argued that children who did not progress to symbolic communication during the three years of the study should receive intervention with a focus on ‘strengthening presymbolic means of communication and providing receptive exposure to symbols’ (p. 74). A number of researchers have focused intervention on enhancing presymbolic communication, with the work of Yoder, Warren, Kim, and Gazdag (1994) providing an example. The intervention in this study was not inclusive of AAC, but rather demonstrated the need for consistent responses to behaviours that meet criteria for intentional communication or can be interpreted as communicative, even if intention to communicate is not evident (Iacono et al., 1998). AAC interventions can mediate between difficult to read signals and consistent responses from people in a person’s environment. As an example, a child

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the benefits of multimodal communication were more widely understood and applied. My argument has been that not all multimodal interventions are AAC. This distinction has relevance in terms of debunking the candidacy model in favour of offering AAC options to any person for whom speech is not functional, whether temporarily or long term. Care is needed, however, in that children who are yet to develop symbolic communication and older individuals who remain nonsymbolic may experience failure if AAC in any modality is introduced with the expectation that they will use it as a symbolic form of communication. On the other hand, AAC systems can change presymbolic behaviours, whether or not they are intentionally communicative, to conventional forms that are readily understood by others, thereby enhancing communicative interactions and empowering the person within their social environments. Integral in any communication intervention, whether or not AAC is included, is increasing the sensitivity and responsiveness of communication partners to all communication attempts, and their participation in and understanding of intervention goals. Multimodal AAC provides individuals with options that can maximise the potential to meet their learning needs and preferences. 1 The distinction between pre-intention and unintentional is made to reflect a developmental trajectory to intentional and symbolic assumed likely for children, but less so for adults who have not demonstrated that progress, unless access to AAC allows demonstration of underlying symbolic competence. References Baumgart, D., Johnson, J., & Helmstetter, E. (1990). Augmentative and alternative communication systems for persons with moderate and severe disabilities . Baltimore, MD: Paul H. Brooks. Bloomberg, K. (1991). Which one for your child. In K. Bloomberg & H. Johnson (Eds.), Communication without speech: A guide for parents and teachers (pp. 30–39). Melbourne, Vic.: The Australian Council for Educational Research. Cress, C., & Marvin, C. (2003). Common questions about AAC services in early intervention. Augmentative and Alternative Communication , 19 (4), 254–272. doi:10.1080/0 7434610310001598242 Edwards, A., Brebner, C., McCormack, P. F., & Macdougall, C. (2016). ‘More than blowing bubbles’: What parents want from therapists working with children with autism spectrum disorder. International Journal of Speech- Language Pathology , 18 (5), 493–505. doi:10.3109/175495 07.2015.1112835 Garrett, D., Beukelman, D., & Low-Morrow, D. (1989). A comprehensive augmentative communication system for an adult with Broca’s aphasia. Augmentative and Alternative Communication , 5 , 55–61. Geers, A. E., & Moog, J. S. (1992). Speech perception and production skills of students with impaired hearing from oral and Total Communication education settings. Journal of Speech, Language, and Hearing Research , 35 (6), 1384–1393. doi:doi:10.1044/jshr.3506.1384 Iacono, T., Carter, M., & Hook, J. (1998). Identification of intentional communication in students with severe multiple disabilities. Augmentative and Alternative Communication , 14 , 102–114. Iacono, T., & Duncum, J. (1995). Use of an electronic device in a multi-modal language intervention for a child with developmental disability: A case study. Augmentative and Alternative Communication , 11 , 249–259.

Iacono, T., Lyon, K., West, D., & Johnson, H. (2013). Experiences of adults with complex communication needs receiving and using low tech AAC: An Australian context. Disability and Rehabilitation: Assistive Technology , 8 (5), 392–401. doi:10.3109/17483107.2013.769122 Iacono, T., Mirenda, P., & Beukelman, D. (1993). Comparison of unimodal and multimodal AAC techniques for children with intellectual disabilities. Augmentative and Alternative Communication , 9 (2), 83–94. Kiernan, C., Reid, B., & Jones, L. (1982). Signs and symbols: Use of non-vocal communication systems . London: Heinnemann Educational Books, Ltd. Konstantareas, M., Oxman, J., & Webster, C. (1977). Simultaneous communication with autistic and other severely dysfunctional nonverbal children. Journal of Communication Disorders , 10 , 267–282. Kouri, T. (1988). Effects of simultaneous communication in a child-directed treatment approach with preschoolers with severe disabilities. Augmentative and Alternative Communication , 4 , 222–232. Light, J., Beesley, M., & Collier, B. (1988). Transition through multiple augmentative and alternative communication systems: A three-year case study of a head injured adolescent. Augmentative and Alternative Communication , 4 , 2–14. Lloyd, L., Loncke, F., & Arvidson, H. (1999). Graphic symbol use: An orientation toward theoretical relevance. In F. Loncke, J. Clibbens, H. Arvidson, & H. Lloyd (Eds.), Augmentative and alternative communication: New directions in research and practice (pp. 161–173). London: Whurr Publishers. Martinsen, H., & von Tetzchner, S. (1996). Situating augmentative and alternative communication intervention. In S. von Tetzchner & M. Hygum-Jensen (Eds.), Augmentative and alternative communication: European perspectives (pp. 49–64). London: Whurr. McLean, L., Brady, N., McLean, J., & Behrens, G. A. (1999). Communication forms and functions of children and adults with severe mental retardation in community institutional settings. Journal of Speech, Language, and Hearing Research , 42 , 231–240. doi:1092-4388/99/4201- 0231 Mirenda, P., Iacono, T., & Williams, R. (1990). Augmentative and alternative communication for individuals with severe intellectual handicaps: State-of-the-art. Journal of the Association for Persons with Severe Handicaps , 15 , 3–21. Musselwhite, C., & Louis, K. S. (1988). Communication programming for persons with severe handicaps . Boston, MA: College-Hill. Reichle, J., York, J., & Sigafooos, J. (1991). Implementing augmentative and alternative communication: Strategies for learners with severe disabilities . Baltimore, MD.: Paul H. Brooks. Remington, B., & Clarke, S. (1993). Simultaneous communication and speech comprehension. Part I: Comparison of two methods of teaching expressive signing and speech comprehension skills. Augmentative and Alternative Communication , 9 , 36–48. Rowland, C., & Schweigert, P. (2000). Tangible symbols, tangible outcomes. AAC: Augmentative & Alternative Communication , 16 (2), 61–78. Sigafoos, J., & Iacono, T. (1993). Selecting augmentative and alternative communication devices for persons with severe disabilities: Some factors for educational teams to consider. Australian and New Zealand Journal of Developmental Disabilities , 18 (3), 133–146.

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World Health Organization. (2001). The international classification of functioning, disability and health – ICF . Albany, NY: Author. Yoder, P., Warren, S., Kim, K., & Gazdag, G. (1994). Facilitating prelinguistic communication skills in young children with developmental delay II: Replication and extension. Journal of Speech and Hearing Research , 37 , 841–851.

Speech Pathology Australia. (2012). Augmentative and alternative communication clinical guideline . Melbourne, Vic.: Author. Speech Pathology Australia. (2015). Scope of practice in speech pathology (Revised). Retrieved from https:// www.speechpathologyaustralia.org.au/spaweb/About_Us/ SPA_Documents/SPA_Documents.aspx Speech Pathology Australia. (2017). Competency based occupational standards for speech pathologists 2011 (Updated). Melbourne, Vic.: Author. Trembath, D., Iacono, T., Lyon, K., West, D., & Johnson, H. (2013). Augmentative and alternative communication supports for adults with autism spectrum disorders. Autism . doi:10.1177/1362361313486204 Wilkinson, K. M., & Hennig, S. (2007). The state of research and practice in augmentative and alternative communication for children with developmental/intellectual disabilities. Mental Retardation and Developmental Disabilities Research Reviews , 13 (1), 58–69. doi:10.1002/mrdd.20133

Teresa Iacono (@Tami_Tagged) is professor of rural and regional allied health and executive member of the Living with Disability Research Centre, La Trobe University.

Correspondence to: Teresa Iacono La Trobe University email: t.iacono@latrobe.edu.au

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Multimodal communication

Improving the ideas behind multimodal communication Scott Barnes

Our society is biased towards communicating with spoken and written language. This has a profound effect on how we all think about communication, and the role of language in it. The idea of “multimodal communication” has been useful for highlighting issues of communication access, but its value as a technical, professional concept is questionable. I argue that we can improve the ideas supporting multimodal communication and transform it into a technical concept by carefully reflecting on the presumptions of our profession, the nature of communication, and nature and functions of the modalities used for communication. As a starting point, we should relate core aspects of communication to different meaning-making modalities, and consider how modalities are combined to achieve communicative acts. In the longer term, this reconceptualisation will provide a basis for more targeted assessment, intervention, and advocacy for people with communication disorders. O ur society is biased towards communicating with spoken and written language. The default expectation that people can understand and use language has a profound effect on how we all think about communication, and the role of language in it. Speech pathologists are mindful of language-based communication expectations, and have a strong sense of how disruptions to understanding, speaking, reading, and writing can limit societal participation. The notion of “multimodal communication” is one of the ways that our profession has responded to these expectations and their implications for people with communication disorders. Our current formulation of multimodal communication provides a basis for articulating how people with reduced access to language can be supported to participate in communication and society. It also provides a basis for advocacy focused on their communication needs. Multimodal communication has therefore been valuable for highlighting common experiences of people with communication disorders, and for defining a politics of communication access. Its value

as a technical concept or construct, however, is more questionable. The way we currently talk about multimodal communication implies a contrast with other ‘forms’ of communication – a “unimodal” communication; or, more realistically, communication that is primarily carried out using spoken language. This is troublesome because – as I will discuss in the sections to follow – spoken language is always embedded in situations that are multimodal (see, e.g., Mondada, 2019). To de-emphasise this fact – explicitly or implicitly – misses the very nature of communication, and risks distorting how we view communication situations involving people with communication disorders. Multimodal communication, does, however, encapsulate an important truth: when people are face to face and communicating, there are multiple, converging streams of behaviour that generate communicative moments. If we are to retain multimodal communication as a platform for speech pathology practice with communication disorders (i.e., use it as more than a basis for advocacy), we must take on the challenge of transforming it into a technical concept by establishing its theoretical and empirical footing (see also Pierce, O’Halloran, Togher, and Rose, 2019). I will argue that this requires careful reflection on the presumptions of our profession, the nature of communication, and nature and functions of the ‘multiple modalities’ in question. Language “bias” People have tacit expectations about the use of language. These expectations become visible in, for example, the joy our clients and their families express upon the successful production of a troublesome sound, word, or sentence. They also manifest in specific expectations about communicating through language. For example, a parent may pursue a child saying the word “hello” to an adult, or the words “I’m sorry” to a sibling. In institutional contexts, uttering certain words at certain times is compulsory for the communication situation, and has life-changing implications (e.g., saying “I do” or “I plead guilty”) (Enfield, 2013, p. 16). So, language is afforded a ‘privileged’ status as a method of accomplishing communicative acts in every part of society. Professional disciplines also have (more and less explicit) assumptions and perspectives on language that shape how they approach it. In general, the disciplinary roots and professional tasks of speech pathology have encouraged us to think about language as separable from communication. For instance, diagnosis of a

KEYWORDS MULTIMODAL COMMUNICATION THIS ARTICLE HAS BEEN PEER- REVIEWED

Scott Barnes

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communication in clinical practice. So, in short, Barnes and Bloch (2019) argue that we do not currently have good theoretical models or measures for the actual process of communicating in real time. This is important because the process of communicating is what we are ultimately aiming to address for our clients. If we do not have well-grounded ways of thinking about communication, then it is going to hamper efforts to provide valid assessment and intervention. Barnes and Bloch (2019) suggest that a starting point for improving how we approach communication is to describe its fundamental properties; particularly, when the people communicating are co-present, which is the basic site for communication (and using language). Essentially, communication involves a two or more people working together to accomplish some practical activity (e.g., a conversation, an interview, a service encounter), and they do this by finely and continuously making sense of each other’s behaviours. Coming to terms with the properties embedded in this description provides a basis for thinking about communication and moving towards sensitive clinical measurement strategies. But what exactly should be measured? There are several aspects of communication that are pervasively relevant whenever people communicate. The field of conversation analysis (e.g., Schegloff, 2006; Sidnell & Stivers, 2013) has been researching them for around 50 years, and there is evidence that they operate in qualitatively similar ways across languages and cultures (see, e.g., Enfield, 2013; Stivers et al., 2009). First, people pay attention to each other’s behaviour for how it is contributing to the ongoing communication situation. At a more macro level, we can call this participation status . That is, communication situations provide various ways of participating (e.g., current speaker–next speaker, judge–witness, parent–child, storyteller–story recipient, friend–friend), and people calibrate their behaviours to enacting their specific roles. At a more micro level, we can call this action . In every moment of communication, people create behaviours that have transparent reasons, or actions. We conventionally refer to actions with speech act verbs (e.g., questioning, complaining, asking, inviting). Determining the reasons for communication behaviours and responding to them is the driving force of every communication situation. Second, communicative actions set up expectations for how others should respond, and for the direction of the communication situation. These expectations are called sequence organisation . Third, and finally, the dynamic nature of communication means that it requires mechanisms for regulating who should participate and when, and methods of fixing problems when they arise. That is, communication requires turn-taking organisation and repair organisation for it to operate successfully and efficiently. These aspects of communication provide its basic infrastructure. More specifically, they set the parameters for how people generate meaning and coordinate their behaviour with others when communicating. I will now outline how this infrastructure is realised via various meaning-making modalities. What are the “modalities” and how are they “multi”? If we are to develop a technical version of multimodal communication, it will be important to specify the modalities within its scope. Speech pathologists tend to think about

language disorder requires us to carefully analyse different components of a client’s language system. In doing so, it makes sense for us to focus on language as a set of relationships supported by specific cognitive processing. However, this perspective also tends to leak into how speech pathologists think about communication. That is, we tend to focus on how language reflects disorder/ impairment rather than how it supports communication (cf. Ferguson, 2008, p. 26). Speech pathology is not alone with this kind of language “bias”. Linell (2005), for example, argues that the field of linguistics is variously biased towards the features of written language, and away from the features of spoken language. As a result, the relationship between spoken language and communication has been treated as inessential by much of mainstream linguistics, which has focused on language as an abstract, independent system that is fundamentally a property of the mind. One of the reasons that people, professional disciplines, and societies prioritise language is its raw semiotic (i.e., meaning-making) power. We can remove language – especially in its written form – from the precise circumstances of its authorship and still retain important parts of its meaning. For example, we can see and hear sentences like ‘Whiskers is a cat’ and ‘Pass me the butter’ and get a strong sense of what they are referring to, and the circumstances in which they could be relevantly used. This creates the illusion that language can be easily set apart from other resources for meaning creation. In fact, for the duration of our lives, spoken language is embedded in communicative moments, and designed to be understood relative to the meanings of those moments and the range of other behaviours co-occurring in them. For example, when people talk, their hands and arms make shapes, their mouths and lips contort, their eyes meet and part, and their bodies shift and rest around one another and the material environment. This is not to say that language is equipotent to gaze or gesture or facial expression; all speech pathologists have observed and experienced the troubles that replacing language with a less powerful meaning-making resource can cause. Instead, I am arguing that it is important to recognise that language is profoundly interwoven with communicative moments and the multiple modalities intrinsic to them. Systematically integrating this fact into clinical practice has the potential for far-reaching effects on how we go about assessing and intervening with communication disorders – and not just for people with complex communication needs, and/or who use alternative and augmentative communication methods. For this potential to be fully realised, however, we must develop more explicit and consistent ways of thinking about communication and multimodality, both individually and together. What is communication? Barnes and Bloch (2019) highlight that our profession does not have an explicit, widely accepted theoretical framework for communication. Instead, speech pathology has tended to lean on models of health and disability when thinking about communication. The profession has also drawn on expert knowledge of the sensorimotor systems and cognitive processing supporting communication, and, at the other end of the spectrum, the implications of communication disorders for psychosocial well-being and participation in society. This theoretical gap has then had flow-on effects for the ways we go about measuring

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multiple modalities as being relevant when people use additional, non-talk-based systems for communicating (Pierce et al., 2019). Another way of thinking about modalities could start from the sensory and motor media through which people convey meaning. For instance, Stivers and Sidnell (2005) draw a contrast between the vocal/aural modality and the visuospatial modality . (Touch also provides a distinctive modality that may be exploited for communication, as do features of the material environment and objects in it.) Within each modality, there are a number of channels . In the vocal modality, there are ‘lexico-syntactic’ and ‘prosodic’ channels, each of which carries distinctive semiotic potential. The visuospatial modality is more diverse, and includes channels for body positioning, gaze, facial expression, and gesture. For people with typical speech, language, and hearing, the semiotic tasks associated with vocal modality tend to be symbolic, whereas those associated with the visuospatial modality tend to be more iconic (Stivers and Sidnell, 2005). 1 The temporalities and sensory presentations of these modalities are also contrastive. The vocal modality is discontinuous, conveyed in short bursts with clear starting and ending points. On the other hand (so to speak!), the channels of the visuospatial modalities are persistently available for people who are co-present (and co-located). This means that the movements, postures, and positioning of peoples’ bodies offers a continuous basis for communication; both with and without the discontinuous signals conveyed via the vocal modality. As one might expect, in typical communication, the vocal modality is used for many communicative functions, with turn-taking, sequences, and repair grounded in talking. However, there are distinctive and recurrent communicative functions that are achieved using the channels of the visuospatial modality. I will now highlight just a handful of examples. At a coarser level, body positioning and overall body movement is central for managing participation status. That is, the way people position their head, trunk, arms, hands, etc., in space (and relative to others) provides important signals for how people are understanding the communication situation and carrying out their role in it (see, e.g., Mondada, 2013). For instance, someone turning their head but not their trunk may indicate temporary involvement in one communication situation, while demonstrating a continuing commitment to another one (Schegloff, 2003). At a finer level, speaker and listener gaze are important resources for managing turn-taking and sequences. For example, both with and without explicit indications in the vocal modality, speaker gaze can signal which person should speak next (e.g., Lerner, 2003) or when a distinctive part of the ongoing communication situation is coming to a close (e.g., Rossano, 2013). Gestures and facial expressions are similarly essential for creating communicative actions. For instance, points and other hand gestures are important for requests, facilitating the listener’s understanding of the upcoming vocal request, and increasing its likelihood of success (e.g., Keisanen & Rauniomaa, 2012). Similarly, facial expressions can be used to project an upcoming evaluative action, and may solicit congruent communicative acts from other people (e.g., Ruusuvuori & Peräkylä, 2009). It is also worth considering just how these modalities come to be integrated with one another. For the most part, people will design their conduct across different modalities so that they cohere into meanings suited to their communicative acts and moments. Put another way, people will employ talk, gaze, body positioning,

facial expression, etc., that is complimentary; both in the sense that they are pulling in the same communicative direction, and in the sense that they carry distinctive mean-making burdens. 2 For instance, saying ‘can you pass me that’, in combination with purposeful gaze and pointing – and undertaken at a suitable communicative moment – will add up into a request for the sauce (or whatever else) from a particular person. So, although the vocal modality (and lexico-syntactic channel) may be in the foreground, communicative acts are best thought of as “multimodal gestalts” (see Mondada, 2019). This means that people communicate using combinations of meaning-making resources across multiple modalities, with each modality combining to become something more than the sum of their parts. In addition, the simultaneity of modalities and their channels makes possible multi-activity (Mondada, 2019). For example, at the dinner table, spirited conversation may be carried out via the vocal modality while the very same people simultaneously coordinate the passing of dishes and condiments via another modality. This simple example highlights yet another important dimension for a technical notion of multimodal communication: the possibly that different modalities are simultaneously accomplishing multiple communicative functions across multiple communicative activities. What’s next for multimodal communication? Multimodality is a pervasive feature of co-present human communication, regardless of the language(s) people speak, the cultures they belong to, the communicative abilities they have to employ, or the practical activities they are engaged in. Our profession’s idea of multimodal communication has been useful for highlighting the communication needs and rights of people with communication disorders in general, and complex communication needs in particular. As a next step, I have argued that we have some complicated thinking ahead to improve the ideas behind multimodal communication (see also Pierce et al., 2019). In summary, this would involve establishing theoretically and empirically motivated approaches to: 1) modalities; 2) relationships between modalities; 3) the communicative functions of modalities; and, 4) the relationships between modalities and practical activities. Embracing the depth and pervasiveness of multimodality in communication will enable us to better capture how communication disorders impact everyday life; especially when people employ atypical configurations of modalities and channels. With this renewed perspective, we can then implement better, and more targeted, assessment, intervention, and advocacy. 1 Of course, languages like Auslan, tactile sign language, whistled registers of languages, etc., demonstrate that there are a variety of ways that the symbolic functions conventionally associated with lexico-syntactic channel of the vocal modality (i.e., words, phrases, and sentences) can be redistributed to alternative modalities and channels. 2 By contrast, some communicative acts (e.g., sarcasm and jokes) are designed to leverage contrasts between modalities (e.g., delivering a ‘serious’ facial expression alongside “non- serious” talk). References Barnes, S., & Bloch, S. (2019). Why is measuring communication difficult? A critical review of current speech

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