Funding Communication Devices and Services:
Writing Communication Evaluations that will Stand up in Court

Sara Sack, Ph.D., CCC-SLP and Sheila Simmons, M.A., CCC-SLP
Kansas University Center on Disabilities-Parsons
2601 Gabriel, Parsons, Kansas 67357
(620-421-8367)

Augmentative communication systems (ACS) serve to overcome the disabling effects of communication impairment through the restoration of normal communication. ACSs are speech prostheses and can be regarded as Durable Medical Equipment (DME).

Communication devices may be comprised of a primary unit such as a computer, dedicated device, manual board, electrolarynx or amplifier and accessories which may include, but are not limited to, output peripherals such as printers, communication application programs, language symbols interfaces overlays, cables and mounts.

Persons are eligible for an augmentative communication system when their ability to communicate using speech and/or writing is insufficient for normal conversation and when it has been demonstrated that an ACS will provide the individual with improved communication. Communication insufficiency is determined by a Kansas licensed speech-language pathologist upon evaluation of that individual. (Eligibility encompasses all persons who have insufficient communication regardless of living and/or personal care environments.)

If a person is unable to communicate using speech, but is fully capable of written communication, this ability to write may, to some degree, offset the impairment of speech communication and render the need for an ACS less acute. Various factors should be considered in attempting to determine if a person's written communication ability offsets their speech impairment to the extent that an ACS is not essential to meet their communication needs. In assessing such persons for an ACS, the speech-language pathologist will determine candidacy by evaluating the person's communication needs, environments and partners to determine if handwriting is sufficient or insufficient as a means of meeting communication needs. The type of communication necessary, the communication environment and the communication partners should be considered. For example, a person in school or on a job may need to communicate with more than one person simultaneously over a fairly large space. The individual would probably be better served by an ACS than by simply writing out a note and sharing it with all intended communication partners. By contrast, an individual who is homebound may have his or her communication needs fully met with a simple writing instrument or typewriter.

EVALUATION AND PRESCRIPTION OF EQUIPMENT

The evaluation shall be conducted by a Kansas licensed speech-language pathologist in conjunction with other disciplines such as physical therapists, occupational therapists or seating specialists as needed. The speech-language pathologist should not be a vendor of ACS systems or have a financial relationship with a vendor.

The prescription shall include specifications for the Augmentative Communication System and the necessary therapy and training to allow the patient to meet his/her communication potential. The prescribed system/components should provide the person with the ability to communicate with any person desired as often and independently as possible.

ROLE OF THE TREATING PHYSICIAN

The augmentative communication device shall be prescribed by the individual's physician, based on the recommendations made by the evaluating speech-language pathologist. The treating physician should review the professional evaluation findings and recommendations of the speech-language pathologist, and prescribe the Augmentative Communication System recommended if he/she feels those recommendations followed a thorough and professional evaluation and are warranted.

Trial Period

If a reasonable doubt exists regarding the ability of the prescribed device to fully meet the individual's communication needs in the most cost effective manner, the device should be prescribed for a trial period of 30 to 90 days duration. The ACS prescribed should be provided on a rental basis during the trial period. It goes without saying that for a rental device to be effective, all necessary components including the mounting systems, appropriate switches, guards, laptray modifications and software must be available in order for the effectiveness of the device to be assessed.

EVALUATION OF CANDIDATE FOR NEED AND APPROPRIATENESS OF ACS

1. Pertinent Background Information

• Medical Diagnosis
• Significant Medical Information/Medications
• Vocational /Educational Status
• Residential Setting
• Social History and Emotional Status

Example:
<Name> is a 7-year-old boy who has a medical diagnosis of cerebral palsy, generalized athetosis and mixed spastic quadriplegia. He does not walk, has a severe speech impairment and requires assistance to meet his basic needs. Although <name>'s current methods of communication are very limited, he remains highly motivated to interact. <Name> lives at home with his parents and a younger brother. He attends second grade at Washington Elementary School. <Name> has received traditional speech therapy since the age of 3 and continues to do so. He has been receiving ongoing evaluation and training in the area of augmentative communication for the past 6 months.

2. Communication Status and Limitations

• Description of Communicative Behaviors and   Interaction Abilities
• Description of Current Communication System
• Limitations of Current Communicative System   Abilities
• Emotional Status as it Relates to   Communication

Example:
<Name> uses a variety of communication modes to express himself. Unaided communication consists of limited vocalization, facial expression, eye gaze and appropriate head nods for "yes" and "no". <Name>'s aided system consists of a 150-word symbol board. <Name> accesses one-inch Picture Communication Symbols with a Viewpointer Optical Indicator. This system provides a telegraphic but grammatical approach to sentence construction and includes nouns, verbs, questions, adjectives, adverbs, prepositions and phrases to help maintain the flow of conversation .

<Name>'s current communication system is inadequate to meet his interaction needs. Due to the constraints of this nonelectronic system, the maximum vocabulary size has been reached. Thus, <name> is confined to an inappropriate vocabulary for his chronological age and intellectual functioning. This forces partners to guess at what he is saying, which leaves everyone frustrated when understanding is not accomplished. In addition, the vocabulary constraints of this system and speed considerations prevent the production of complete sentence structure. <Name> is unable to interact with his peers as they are unable to see or follow this graphically-based system. He cannot communicate across any distances and is therefore confined to interacting with individuals who are familiar with the system and who are standing next to him. When an attentive adult is not available to interpret messages (which is frequent) <name> becomes withdrawn and distractible.

<Name> is confined to "yes/no" responses when he is lying down.

3. Candidacy for a Communication System

Statement of Candidacy for an Augmentative Communication System

Example:
<Name> is an excellent candidate for an electronic communication system. The prognosis for the development of functional speech is extremely poor and <name>'s current nonelectronic system is very limited. An electronic aid would significantly increase his ability to interact.

4. Speech and Language Skills

• Prognosis for Speech
• Language Skills Comprehension Expression   Linguistic Skills
• Prognosis for written communication

Example:
Although <name> has had years of traditional speech therapy, he has not developed functional speech. He exhibits severe respiration, phonation and articulation disorders. Respiration is shallow and characterized by oral breathing. He is unable to sustain voicing or maintain volume levels sufficient for intelligible speech. Vocalizations are limited to vowel-like sounds. Although it is still hoped that <name> will develop some speech capabilities in the future, it is the evaluator's opinion that he will not develop sufficient skills to meet his communication needs.

<Name> demonstrates an understanding of complex syntactic constructions and many linguistic concepts. Comprehension of language is within normal limits.

The prognosis for producing manual written materials is very poor.

5. Cognitive Status

Statement of Best Known Status

Example:
<Name> demonstrates an excellent ability to learn and maintain information. He has shown sufficient memory capacity to use semantic encoding techniques .

6. Communication Needs Assessment

• Communication Partners
• Conversational and Written Communication   Needs Placement of
• Communication System in Relation to the   Individual's Position (s) and Mobility
• Status
• Integration with other Technology
• Individual's and Primary Communication   Partner's Wishes and Needs Re:
• Communication
• Communication Modality

Example:
An assessment of communication needs revealed that <name> requires a communication system that will allow him to produce multiple types of messages with unrestricted partners in any environment. Voice output is essential to meet these needs. The system must accommodate expected cognitive and linguistic growth. <Name> must have access to the system in a variety of positions, particularly sitting and lying down.

7. Postural and Mobility Status

• Statement of Mobility Status
• Information Regarding Optimal Positioning as   Related to Pelvis, Trunk, Head
• Position and Control Site, if Indicated
• Integration of Mobility with Communication   System

Example:
<Name> is generally seated in a wheelchair, or a chair specifically designed for his use. Chairs for <name> have adapted insets which provide good support for trunk alignment and stability. When seated <name> has enough head control to use a headpointer or an optical indicator.

8. Sensory Functioning

• Visual Ability--as related to communication   systems
• Auditory Ability--as related to communication   systems

Example:
Audiological (11/95) and ophthalmological (9/95) evaluations revealed that auditory and visual functioning are within normal limits. <Name> can identify picture symbols that are 1/2 inch in size and letters that are 1/8 inch in size. He demonstrates the ability to understand synthesized speech.

9. Access

• Individual's Ability to use a Variety of   Techniques to Access a Communication System
• Describe optimal access technique(s)
• Describe selection method

Example:
Although <name> can use a variety of techniques to access a communication device, optical indicating is the optimal method. <Name> has no functional use of his arms or hands in any position. However, he can use a number of headpointing techniques to access symbols via direct selection when he is in a supported sitting position. Although <name> can use a headstick to indicate symbols, his range is limited and he becomes fatigued when using this method. With optical indicators <name> has excellent range. He is very accurate and does not exhibit fatigue. <Name> is able to access the Real Voice and Light Talker through optical indication in a sitting position. When lying down, <name> can move his head to the left or right to activate a plate switch. Using a switch <name> can access symbols with row-column scanning techniques.

10. Symbol Form

• Individual's Abilities to use Various Symbol   Forms
• Describe Optimal Symbol Form

Example:
<Name> currently uses Picture Communication Symbols. The alphabet has been introduced and <name> is beginning to learn sight words. An appropriate electronic system would need to have spelling and writing capabilities to meet future needs. With spelling capability <name> would have access to unlimited vocabulary, an essential need for social, linguistic and intellectual development. Within approximately a year, <name> will need to produce permanent written material to leave messages for nonpresent partners, make personal notes and to participate in the educational process.

11. Delineation of Features of Communication System

Device Specifications for most Effective and Efficient Communication. These may include:

• Vocabulary capability/amount and expandability
• Symbol form
• Output modes
• Intelligibility of output modes
• Rate of message production
• Correctability of messages
• Independence in producing messages
• Device construction and adaptability as related   to access
• Portability
• Integration with other technology
• Access/selection techniques
• Future expansion capabilities
• Language expansion and rate enhancement   techniques

Example:
There are a number of required features that a device must have to allow effective and efficient communication and meet future needs. A large memory capacity is necessary to accommodate present and rapidly expanding vocabulary.

<Name> needs a visual display that will permit the presentation of picture symbols as well as orthography. He requires voice output to permit interaction with peers, initiate conversation, call for assistance and converse in a group setting. A device must be capable of interfacing with a hard-copy printer and should be capable of interfacing with a computer for future needs. A device should be highly portable and permit access through optical indication and switch activation, thus allowing access in a range of environments and physical postures. The device should have a delete function to permit the unambiguous repair and correction of utterances. The system should include software that allows a grammatical approach as well as encoding approaches such as abbreviation expansion and semantic encoding. This would permit the construction of unique telegraphic phrases and the production of entire prestored sentences as well as enhance speed.

12. Consideration of Communication Systems and Components Meeting the Individual's Needs

• Communication Systems that were Considered   for the Individual
• Comparison of System's Capabilities

Example:
The Light Talker and Real Voice were introduced and considered for <name>. Although these two systems both provide all of the required features the construction of the devices and the methods of assessing grammatical and encoding approaches are significantly different. The Real voice requires that a light pointing board be interfaced, via a cable, with the main system to provide access through light pointing and scanning. The single piece design of the Light Talker seems to be less cumbersome and more durable for a young child. The Light Talker has 128 symbol cells as opposed to 105 on the Real Voice, thus allowing for a greater number of picture symbols to be displayed. In addition, a greater number of selections are required to switch between a grammatical approach and an encoding approach on the Real Voice, rendering this system somewhat more complicated to meet this specification. Therefore, the Light Talker was recommended for a one month trial period.

13. Ability to Learn and Use Communication System/Components Under Consideration

• Trial of System and Components
• Trial with Primary Communication Partners when   Possible
• Comparison of Individual's Ability to use   System(s)

Example:
During the 1-month trial period <name> used the Light Talker throughout the school day and at home. The system was mounted on <name>'s laptray. Vocabulary and symbols were primarily selected from his manual system to simplify the evaluation of <name>'s ability to use this device. <Name> exhibited an excellent ability to use this system. Family members, staff and classmates demonstrated the ability to understand the synthesized speech.

14. Communication System Prescribed and Justification

• Description
• Indication of Purchase or Rental with Statement   of Justification. If Rental is Indicated, Include   Plan for Transition to Purchase
• Statement as to why this System is the most   cost Effective
• Benefits to user over other Possible Systems
• Ability to meet Projected Communication Needs
• Statement as to how this System will Provide the   Necessary Rehabilitative, Prosthetic and   Preventative Goals of Communication

Example:
Based on the evaluation and training process it is the evaluator's opinion that <name> is an excellent candidate for an electronic, prosthetic, communication aid and that the Light Talker would be the most appropriate system. As <name> is young and highly motivated to communicate, it is believed that a system without all of the above noted features would obstruct linguistic, social, and cognitive development as well as possibly cause secondary problems such as withdrawal and distractibility. The Light Talker is an averaged-priced device for a system with its capabilities. It is believed to be a cost-responsible choice. With the addition of the printer in approximately 1 year, this device should be appropriate for the next 5 years.

15. Treatment Plan and Follow-up

Development of a Treatment Plan. This Plan will Include the Following: Short and long-term communication goals

• Persons responsible for training
• Projected changes in system, if appropriate
• Initial training and basic use of communication   system
• Implementation and integration into   environments
• Necessary construction or modification of   system to suit the user

Example:
<Name> will remain in the augmentative communication training program. The evaluator/clinician will have primary responsibility for this program. A new in-depth vocabulary analysis has been undertaken to insure appropriate lexicon selection. Goals during the next phase of treatment will include, but not be limited to, the integration of the Light Talker into a variety of environments, improving interaction skills with particular emphasis on communication with peers and educators, and establishing literacy and spelling skills. Mr./Ms. <teacher> has participated in individual and group sessions for partner training and will continue to do so. Overall, it is the evaluator's opinion that the prognosis for independence and good communication skills will be greatly enhanced with the provision of a Light Talker.

RECOMMENDATIONS

1. Light Talker with the single rocking lever switch (medium force) and the direct selection optical sensor.
2. New Laptray to be designed for mounting and protection of the Light Talker.
3. Although not to be ordered now, will need a printer in approximately 1 year.

Thanks to:

Deborah Buck of the New York State Advocate for Persons with Disabilities (The TRAID Project) and to Debra Zeitlin, Center for Rehabilitation Technology, Helen Hays Hospital, West Haverstraw, NY for sharing information, experiences, and case studies.