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Dr. Caroline Ramsey Musselwhite

Wednesday, June 26, 2019

AAC in the Cloud Presents - Stories of Ourselves: Family Photo Fun

Anybody looking for the slides from this session, please click here

To watch the recorded session on YouTube, please click here

Monday, June 17, 2019

Stories of Ourselves: Building Social-Linguistic Skills of Learners with CVI

Five broad instructional strategies are emphasized in the trifocus framework as synthesized by Bruce and Bashinski (2017): enhancing (partner) sensitivity, utilizing routines, increasing communication opportunities, modifying the communication environment, and augmenting input. Stories of ourselves are a great context for all 5 of these strategies.  

Enhancing partner sensitivity involves understanding how a learner responds to the world around him/her.  Visual (and auditory) processing difficulties may result in behaviors that appear defiant or non-functional.  The term CVI has been used to refer to Cortical Visual Impairments (Roman-Lantzy, 2017, 2018) and Cerebral Visual Impairment (Lueck & Dutton, 2015).  Both terms refer to visual processing challenges that are the result of brain damage rather than damage to the eyes.  We use the term CVI when referring to learners of any age who appear to have normal visual structures, but function in ways that point to problems processing  their visual world.  This affects their ability to safely move around the environment, manipulate objects, watch what other people are doing, and even notice facial expressions.  For those whose brain damage also results in severe physical impairments, it can be difficult to determine how and what they are seeing and hearing.  Fortunately, a team-based approach can heighten awareness and empathy of those surrounding this person, and result in strategies and experiences that can result in real changes to brain function and systematic improvements in social-linguistic skills.  Stories of ourselves can be used to build awareness of how a person functions in his/her world.  During shared reading (Erickson, 2017), partners can be more aware of the visual processing challenges posed by expecting somebody to read facial expressions, look where somebody is pointing, and recognize images on the page.  Only when we are empathetic and sensitive to the challenges can we make appropriate accommodations.  

Utilizing routines can be a tremendous comfort to learners with sensory processing impairments.  Understanding that an activity has a beginning and an end can build confidence to explore.  Stories of ourselves can be used as a way to talk about routine activities.  Deaf-Blind literacy resources suggest use of “Experience Stories” and “Experience Books” as a way to share and review what has happened, while at the same time building new concepts (example here: https://www.wsdsonline.org/video-experience-books/).  In this way, our stories build social-linguistic connections.  Bridge School experts recommend using Home News as a routine for home-school connections (http://curriculum.bridgeschool.org/areas/cc/strategies/connections/homenews).  Sharing a brief personal story within a predictable routine can build social-linguistic skills by incorporating the recorded voices of family members and friends in a context that is relevant and meaningful.  Family bedtime stories can become part of a routine that provides a quiet environment with relatively few distractions.  Routines that incorporate movement and rhythm can also result in short stories about ourselves and what we are doing, and can be sung throughout the day.  Consider Musselwhite’s songboard, “Take the Hat” (currently under revision) and familiar children’s songs like, “I like to eat, eat, eat apples and bananas.”  Consider the attendance routine in preschool when students greet each other with song and movement (Musselwhite, 2015).  The amount of movement and activity can be a sensory overload for some with visual and auditory processing challenges.  Offering this activity during a quiet one-on-one shared reading time, reviewing a story about who came to school today, may allow some learners time to process and attend in a more meaningful way. 

Increasing communication opportunities is the third strategy in the tri-focus approach.  When a student feels safe and secure, he/she is more likely to reach out and explore the world.  Careful observation of self-directed movement and signs of engagement can be key to building joint attention.  Partners need to recognize communication styles and build personally meaningful experiences through joint attention.  Since students with CVI may not have access to the same visual signals as their peers (or partners), we need to carefully consider how to engineer communication opportunities that foster learning social-linguistic patterns.  Building on the idea of maintaining an attitude of empathy and utilizing routines, communication can take place when something unexpected happens.  Stories of ourselves can be a way to talk through the “what if” scenarios.  We can structure personal stories with clear conversational contexts.  For example, a story about what we do when it is time for lunch can help a learner identify environmental cues about lunch time and gain explicit instruction from the story about what he or she could do to let somebody know what he is thinking at the time.  Quite possibly school lunch routines are heavy on sensory input that involves lots of movement, and can be overwhelming for a student with CVI.  Rather than expecting the student to activate a message on a communication device that says, “I am hungry” when it is time for lunch, we need to consider carefully what the person is telling us by his/her responses to the environmental cues.  We can use a personal story that reflects on how somebody might feel and what choices might be offered.  Careful identification of motivators will help conversational partners identify communication opportunities.  However, we need to keep in mind that requesting a motivator is only one function of communication.  Opportunities to complain, question, and comment may need to be strategically planned.  In this way, the context of a personal story can be used to build social-linguistic skills. 

Modifying the communication environment for students with CVI may include reducing competing sensory information and reducing the complexity of visual information (Tietjen, 2019).  Different strategies may be appropriate, depending on the level and severity of CVI.  Using the results of the Range for CVI (Roman-Lantzy, 2018) and recognizing the potential for change over time can result in significant changes in social-linguistic connections.  Some students with less severe CVI may benefit from consistently-worded descriptions of key visual features of elements in their environment.  Communication partners who are sensitive to sensory needs and necessary adaptations can find meaningful ways to use movement and auditory signals separate from visual processing requirements.  We need to recognize that some students with CVI turn away or close their eyes when they are really paying attention to choices being offered through auditory channels.  Stories of ourselves can be used to inform others about what the learner does when listening to choices.  Through personalized stories, we can describe environmental adaptations that provide a secure environment that facilitates personal expression and engagement.  

Augmenting input is often understood to mean pointing to symbols on an AAC system as we speak.  Some learners with CVI may not be able to see what the person is pointing at or to visually recognize the referent.  In this case, the “augmentative input” is not matched to personally meaningful social-linguistic constructs.  We may actually be introducing elements that result in increased stress.  To avoid toxic stress, Scoggin (2018 Fall Special Topics Workshop, Connections Beyond Sight and Sounds) recommends building a feeling of competence by giving the learner time to process information through channels that are accessible and personally meaningful to him/her, building anticipation based on familiar routines and interests, waiting for the individual to initiate movement, following the child’s lead, and imitating what he/she does.  When an individual has something to say and does not use symbolic language, we can notice the way they orient their bodies and use their vocal expressions to the best of their abilities (Communication Matrix).  Rather than expecting the person with CVI to imitate a communication partner, the partner also needs to learn how to mirror the communication skills of the individual.  Therefore, augmented input can vary from individual to individual.  For those with the most severe levels of CVI, input may be primarily auditory.  But if the student has some functional vision, we need remember to include that as an anchor that can build joint attention.  Augmenting input can come in the form of drawing attention to visual information through an auditory channel.  Stories of ourselves can be used as the context for providing a concrete visual anchor while we introduce ways to access auditory messages to talk about the item.  For example, a story about a favorite toy can include a concrete representation of the toy.  During shared reading about a personally meaningful item/event, visual attention may be focused on the item in the book.  For some this may require a physical connection with some tactile elements of the toy/event. Once we have established a joint reference, we can use a story to provide examples of how a child may respond to choices from an auditory scanning system.  A robust auditory scanning system must incorporate multiple communicative functions.  Using a story that explains what can happen when a learner indicates that he/she “has something to say about that,” and chooses one of the auditory options, can explicitly and selectively demonstrate communicative branching to build social-linguistic connections.  For example, in the context of reading a story about playing with his/her favorite brightly colored ball, auditory branching from the communication system may offer choices such as: me/mine, want, more, like, questions, all done, you/yours.  Using a PODD auditory scanning book can provide consistent structure to a branching system (explore resources from Porter, Burkhart, and Farrall). Therefore, a personal story may include what happens when the learner selects the auditory option for “me/mine” and is given the ball to play with.  After some time interacting with the ball, the partner waits for attention to return to the story before going on to the next page.  Giving the student a way to turn the page electronically may be the best way to signal that he/she is ready to move on.  The next page of the book can show the same ball, but this time signal that a different auditory option can be selected.  The context of the book, therefore, offers a concrete structure for choosing a different item from the auditory scanning options and expands experiences.  If the individual does not select a different item from the auditory list, the communication partner may need to demonstrate this.  Turning to the next page can be like choosing the second item from an auditory scan (e.g., recurrence).  Then when it is time to go to the third page, the auditory scan can again be initiated and used to signal that this book is about what happens when the third item in the list is selected (e.g., commenting - leading to expressions of pleasure).  A fourth page can demonstrate choosing another branch (e.g., questioning - leading to asking who/where).  The last page in the book can demonstrate what happens when we choose a termination message (e.g., all done).  

So there you have it!  When we use principles that incorporate a tri-focus approach, and apply that to personally meaningful and accessible learning opportunities, we can put in place a plan that addresses the needs of all students, including those with CVI.


Bridge School experts (unnamed and undated) recommend using Home News as a routine for home-school connections.  http://curriculum.bridgeschool.org/areas/cc/strategies/connections/homenews  

Bruce & Bashinski (2017).  The Trifocus Framework and Interprofessional Collaborative Practice in Severe Disabilities.  Published by American Journal of Speech-Language Pathology, Copyright ASHA.  Download from https://doi.org/10.1044/2016_AJSLP-15-0063 

Burkhart (undated).  PODD links for ordering, handouts, and workshops.  http://www.lindaburkhart.com/podd.htm

Communication Matrix (undated).  www.communicationmatrix.org 

Erickson, K. (2017). Comprehensive Literacy Instruction, Interprofessional Collaborative Practice, and Students With Severe Disabilities. American Journal of Speech-Language Pathology, Vol. 26, pp 193–205, May 2017. Downloadable from: https://pubs.asha.org 

Farral, J (2019). Literacy, AAC and Assistive Technology.  Resource includes links to workshops and blog posts.  For 2015 PODD Tips from Interactive Speech Pathology, link to http://www.janefarrall.com/getting-hands-on-with-podd/ 

Lueck & Dutton, Eds. (2015).  Vision and the Brain:  Understanding Cerebral Visual Impairment in Children.  AFB Press. Includes Chapter 4 by Fazzi, Moliaro & Hartmann, titled: “The potential impact of visual impairment and CVI on child development.” AFB Press.  ISBN-10: 089128639X; ISBN-13: 978-0891286394.

Musselwhite (currently under revision).  Singing to Learn CD.  Order form http://www.aacintervention.com/home/180009852/180009852/docs/Software%202-06.pdf 
Based on Caroline’s Tips 1-4 from 2015.    http://www.aacintervention.com/page/180009852/180103625/2015-TIPS-1-4

Porter, G.  (2009). Pragmatic Organization Dynamic Display (PODD) Communication Books: A Promising Practice for Individuals With Autism Spectrum Disorders. Article from Perspectives on Augmentative and Alternative Communication 18(4):121-129 · December 2009. DOI: 10.1044/aac18.4.121

Roman-Lantzy, C. (2018). Cortical Visual Impairment: An Approach to Assessment & Intervention. AFB Press, 2nd Edition. ISBN-10: 0891286888; ISBN-13: 978-0891286882

Roman-Lantzy, C. (2019). Cortical Visual Impairment Advanced Principles.  Including chapter by
Mark Tietjen on “What’s the Complexity” Framework. AFB Press. ISBN-10: 1616480076; ISBN-
13: 978-1616480073

Scoggin (2018).  Part of the annual Technical Assistance training opportunities offered by Connections Beyond Sight and Sounds. This event was originally scheduled as the 2018 Summer Institute, but due to logistics, was rescheduled as the 2018 Fall Special Topics Workshop. “Emergent Literacy Ideas for Complex Learners” — presented by Kathee Scoggin.  Downloadable PPT and other materials from the workshop can be found here:  http://marylanddb.org/2018/05/08/2018-summer-institute-registration-open/

Washington Sensory Disabilities Disabilities Services (undated).  What is an “experience book?” Found at https://www.wsdsonline.org/video-experience-books/