 Hello, I'm Susan Levy. My colleague Bruce Bailey and I are from the Maryland Division of Rehabilitation Services. We both work at the Maryland Rehabilitation Center in the Department of Rehabilitation Technology Services. Bruce and I work in the Demonstration Center, which is funded by the Maryland Technology Assistance Program. Both the Division of Rehabilitation Services and the Technology Assistance Program are federally mandated programs, so you'll probably have a similar program in your state. Susan and I are going to be giving you an introduction to devices relating to augmentative and alternative communication. As you can see, we have a wide range of devices available. Our presentation format is of show and tell. We have picked out devices that sample a good range of the types of features you're likely to encounter in your line of work. These are not necessarily the best products, and they're certainly not the only products. There are hundreds of devices available. I was amazed when I got into this field to find out how many manufacturers and products and how much market there is for what I thought was a very narrow slice of the population. I was astounded to find out, for example, that there are half a dozen companies that derive a good income just making the picture symbol systems that go on the devices, the little stickers you're going to see on many of these displays. Communication is about people understanding each other. And I want to be sure that you understand us when we talk about augmentative and alternative communication. Augmentative communication is when people use a method in addition to speaking to help them get their ideas across. We all do this every day. We use facial expressions, we use body language, we use hand gestures, and we use sounds to help us express things. For instance, have you ever tried to describe a spiral staircase without using your hands? It's very difficult to do. We all either spiral our hand up or we spiral it down, but we use our hands and that helps us to get the idea across, and it helps the listener to understand us better. Alternative communication is when we use some method other than speaking and don't speak at all. And we all do this too. It's not that unusual. We sit in a restaurant, we're waiting for somebody and they come in and we wave at them. Or we're in our car and we're trying to change lanes. Some courteous driver lets us in and we give them a little wave of thank you. Or we're driving in our car and some discourteous driver cuts over and cuts us off and we shake our fist. And everybody knows what these things mean. We use alternative communication when speaking is impractical, impossible, or if we just wouldn't be heard. For some people with disabilities, speech is difficult. For these people, they usually produce speech, but it's hard for us to understand them. In these cases, it's practical for them to use alternative or augmentative communication. Because most people do speak in some way, from here on we're going to talk about all these systems as augmentative communication. In the field of assistive technology, we generally refer to devices as being no-tech, low-tech, or high-tech. No-tech systems means not using any device at all, just using your hands. No-tech systems can be very sophisticated. American Sign Language is a very complicated, sophisticated method of communication. Gestures aren't much less sophisticated, but they're readily understood. Because our focus is on assistive technology, we are going to be talking about only the devices that include low-tech and high-tech devices. Low-tech devices are generally paper, non-electronic systems. Something simple like communication wallets, all the way up to perhaps light-point with battery devices. High-tech solutions can be much more complicated and would include, for example, computer-based systems. We'll be presenting systems from low-tech to high-tech. We're also going to focus primarily on picture and icon-based systems, because of our understanding that most of the people that you work with are not literate. We want you to be aware, however, that there are letter and word-based systems also available, and these give additional flexibility. First, we're going to start with low-tech, picture-based, non-electronic systems, which are often used by people who may have access to higher-tech systems or who may have high-cognitive skills, but use them because they have certain advantages. These are also very good backup systems for when your high-tech system breaks down. Our first example is a picture menu from McDonald's. This picture board has many good features. It's colorful and attractive. It uses high-contrast photographs for the communication message. The color photos are very concrete and easy to be understood. It is perfectly suited for the task of ordering breakfast at McDonald's. There are some serious drawbacks with this system. What percentage of the day do you spend ordering breakfast at McDonald's? In this example highlights one of the fundamental issues with non-electronic communication aids in particular and augment of communication devices. A communication system must be tailored to the individual's needs, abilities, and wants. It must be tailored to the situation and setting, and it must be tailored to the specific activity and task. One other serious drawback with McDonald's system is that it does use photos of real objects, and it's very difficult or not impossible to use photos to convey more abstract meanings, such as adverbs, adjectives, verbs, and other parts of speech. There are commercially available picture boards from a number of companies, and this one that we'd like to show you is called Picture Communication Symbols, and it's from a company called Meyer Johnson. This board is much more organized than the McDonald's board that you saw earlier. It has, in this color-coded section, it has the subject for sentences. In the green color-coded section, it has verbs for sentences. In this area, it has a few connecting words, then it has a couple of adjectives and adverbs, and then in this larger orange area, it has the objects for the sentences. It also leaves a number of spaces blank so that you could personalize this board. It has certain kinds of organization because it's part of a series that are going to stay consistent. It has a space here where you can request help. It has another space where you can request a different board from this communication system or a different communication system to be substituted. It has yes and no here on the board, although I'd like to note that the majority of people have some other way of making yes and no that's more efficient than using a board. The boards each have their own theme. This board is about washing up in the bathroom. Here's another board from that same series, and you'll see that it's organized exactly the same way. The color codes are the same. They still have all the subjects for the sentence here and the verbs here, the connecting words, the adjectives and adverbs, and the subjects here, and they still leave some spaces for personalization. Yes and no are in the same place. The request for help is in the same place, so you always know where to find it. And the request to change communication aids is also in the same place. This is about making a sandwich and selecting what's going to be on it. Let us change gears for a moment and talk about what it's like to interact with somebody who is a consumer of these assistive technology devices. Probably at your introduction with the person, you're going to want to make sure you understand how they say yes and no. It's also probably going to be helpful to watch how they interact with a familiar listener, perhaps a staff member. Yes and no is very important because if you get off track, you're going to need to know how to be corrected and know where to start again. There are some techniques you're going to have to do when you work with a person. Probably you will be expected to read back whatever they point to, or you may be expected to make some guesses and inferences. When you first meet a person who's using an augmentative communication system, and you as a surveyor are going to need to ask them some questions, you might want to start off with just making some small talk. Just ask them, how are you? And see how they respond. Do they go right for their board? Or maybe they'll go for their board and tell you something different about themselves. That's fine. Just watch and see what their response style is like. Suppose you ask somebody a question and nothing happens. Well, you're probably going to have to go into a very relaxed mode. Take a breath, count to ten. That's a very long time, but the person may need that much time to formulate their thought to start their body moving and getting to make the right selection. Frequently, people who use augmentative communication devices have instructions that are written right on their board or device to help a new communication partner understand how to interact with them. And it's perfectly okay for you to ask that person to hand you their board or their device for a minute so that you can read the instructions. Also, if you've asked a question and the person hasn't been able to respond, you might want to read the board and see what's on there so that you'll know how to phrase your question correctly for them. It's perfectly okay to say to them, wait a minute, let me take a minute and read your board. The boards have a lot of flexibility since they've been targeted to a specific situation. And if you're working with a familiar communication partner, that interaction is going to be very, very fast, much faster than you could get with a high-end electronic system and a novice partner. There's also a lot of good social interaction when you're working with a communication partner. Many consumers really like that. The non-electric communication systems don't have to take the shape of a board. This is a system that's on a ring and allows you to flip through different pictures to communicate what you may want or need. You can carry it just like a set of keys. This is a small booklet that's called a communication wallet because you can just slip it right in your pocket like a wallet. But there are booklets that come in other sizes too so that what meets your needs in terms of your ability to handle things or your vision is available. It can be larger than that or it can be as small as this. There are commercially available systems out there that can give you enough vocabulary to go shopping and have a whole shopping list that you can put into your communication book or wallet. This is one that was developed specifically for going to the drugstore and it has a lot of things in it that you might be able to buy either in a drugstore or a grocery store. We've been making the assumption that our augmented communicator has the ability to reach out and manipulate some of these objects at least to be able to point to different cells or pictures. That's frequently not the case. You can still use some of these low-tech systems with people that have a lot of physical involvement. I'd like to demonstrate a light pointer. This is basically a high-tech flashlight. It's a way to do direct selection with a minimal of movement. Susan's going to repeat after me as I make my selections. I eat more sandwich. You'd like to have another sandwich? If direct selection with finger or light are not possible then the communication partner may need to resort to a facilitated scanning technique. We're going to show that. I'm going to use a head nod to tell Bruce when to stop moving his finger across this board and he's going to scan across the columns and then down the rows. I help make tuna. You're going to help me make the tuna. Great. There are other even more concrete communication systems that are available. This device is called the OptiCommunicator and it works off of eye gaze in a very concrete symbol system. It's actually using real objects. If you meet someone for whom this is their only form of communication then you're going to need to tailor your questions to the possible responses that they have because they're very limited with having only four possible things that they could say. There are of course some real deficits with these systems. They can be very difficult to manage. They require a lot of preparation ahead of time. Some of these devices are not very portable. They also use the pictures which are cognitively a little bit more abstract than speech and if the communication partner doesn't cooperate you can't have a conversation with them. These deficits are the primary reason people move to electronic voice-based systems. They give the user of the devices much more independence and a lot more control and they're not nearly as dependent on the skills of the communication partner. We're now going to sample some voice output communication aids. We're going to visit these in increasing levels of sophistication and cost. We're going to start with a sampling of a few that are priced under $600. This is kind of an arbitrary cutoff that we use for our own convenience. One of the simplest devices is the Big Mac switch. Hey, what's your watch? Hey, what's your watch? It's basically a high-tech tape recorder in a special shape. This has an appropriate message for, say, being near a kitchen or on the refrigerator. Very easy to reprogram this. Say if this Big Mac switch was going to be set on top of a television set it might have a different message. Hey, change the channel. This is dumb. Let's watch something else. Change the channel. This is dumb. In any case, the vocabulary for this device and any of the other communication devices has to be set up ahead of time. Next, we have a device called the Speak Easy. It's by the same company and its name principle is the Big Mac. Only now, instead of only one message, we have twelve. Yes. Thank you very much. I'd like to get dressed now. I'm thirsty. I'd like a drink. This device also does recording just like the Big Mac. It's just as easy to program. You just push a switch to put it in program mode until you push the button and talk into it to program it. This is also the first device that we're going to see that will take an external switch to operate it. For some people, it's really difficult to reach up and push these small buttons. On this one, you could plug a switch into any of these buttons and get the speech output by operating the switch, maybe with my face. Thank you very much. Ability switches come in a wide range of formats. Most are mechanical switches. Some take a very great ideal amount of force and some take much, much less. Some switches come, are designed to be mounted for maybe use near a head, chin, knee, or really any body part that you have good control of. This micro switch is actually designed to be worn on a headband by raising your eyebrow. It's a string switch. The loop is designed to go around a finger or a thumb. Some of the switches are a little bit more exotic. This is an example of a finger flex switch that works, it fits on the hand pretty much like a glove. This switch is actually a tilt switch. There's a little piece of mercury inside there and it works from knotting the head. This is an example of a sip and puff switch worked by breath control. And then switches can get even more exotic and much more expensive. This switch is an eye blink switch. It's positioned on a pair of glasses with this clip and you can activate some of these devices just by blinking an eye. And then at the very high end we have the twinkle switch, which is a PZ electric switch. Actually you put these pads on and it works senses muscle movement, either perhaps a clenched jaw The point is to have the switch work with whatever repeatable non-tiring movement the person has good control over. One problem would say the speak easy is that it's going to require 12 different switches, which may not be possible to physically arrange switches to make those convenient to use and if you need the higher end switches you can't afford to spend several hundred dollars to work the speak easy because they're not going to have enough space on their head to work all of them. The next device we're going to show we're going to show it in a little bit, we'll have another device that will work for a single switch to access all of the cells that are on the device. This next product we're going to talk about is called the wolf. This one doesn't happen to take ability switches so the person does have to push these buttons with their finger. We're going to use this to demonstrate something else. This is the first device that we're going to look at that uses synthesized speech. This is programmed with things we say around work all the time. We get out of equipment, we say please work, please, please work, please work. But could you understand that? It's a little hard to understand and it doesn't have a really pleasant voice. That's why this particular device only costs four hundred dollars. Synthetic speech is available in a wide range of qualities and this is the low end of that. This particular device is a little hard to understand. It's hard to program but it is inexpensive. This guy is the message mate and it's another press the button and it talks kind of device very similar in that respect to the Speak Easy. The difference with this device over the Speak Easy is that it will accept a switch to arrange for what we call scanning. I just plug the ability switch into the device and it's ready to go and I might have the switch mounted near my head and you see the light moves across to the display column by column. When I get to the column that I want the light sequences between the two choices there let's go to that last column again so this is set up to make some choices. The other thing I really like about this device is that it's indestructible. Sorry messed up your table and it's all ready to work. Very frequently consumers of these devices do not take good care of them as frequently as not the staff may be very hard on the equipment as well. The difference between communicating with someone who's using a picture communication board and someone who's using an electronic communication device is that when you're talking with someone who's using an electronic device more than likely you're going to be face to face with that person in a normal conversation. When you're talking with someone who's using communication board you're going to probably have to be to their side so that you can see where they point and read their board. That may vary a little bit depending on the style of the particular person but usually that's going to be the case. With either kind of augmented communication user you're going to have to ask your question and wait and be patient and watch and see how they're going to try to respond to you. It's pretty easy to make accidental selections with these devices as well. I do it all the time just when I'm trying to demonstrate them. So the user of the device might have some of that difficulty as well. If you get an answer to a question that seems totally out of context just pause, wait a second make sure that the augmented communicator is satisfied with their answer. It's best to just ask one question at a time. You have to pause and see how they're going to respond. If you bombard the person with questions is that what you meant to say? Should I ask the question again? Where do you want to go next if we're done here? Which of those questions do you want the person to answer? They're not going to know which question they're supposed to respond to. The biggest limitation with the devices that we've seen so far is that you only have a few possible things that you can say. They need to be programmed for the specific situation that the person's in. They're fairly easy to reprogram but you're going to have to do that continuously through the day. You may be able to put enough vocabulary in one of these devices to get through lunch or to get through playing a game but you're not going to have enough for every activity of the day. The next group of devices that we're going to look at are a lot more sophisticated than the previous. They'll store hundreds of messages so that they will have enough space to store enough messages to get you through a whole lot of these activities. Each device that we're going to show you also can have a variety of kinds of access through switches and so forth so that people can use them in a lot of different ways. These devices, however, all cost more than a thousand dollars. The first device that we're going to look at is the Digivox. Again, it's a recorded digitized device. It has paper overlays that you can design and program yourself. Each overlay or level can have up to 48 messages on it and this one is programmed for several levels of 32 messages each. I need to select the level that matches the paper overlay that I'm using. This one is level 2 and the device is already set for level 2. So when I push the one, this button it says on the overlay, hi how are you and that's what the machine says. This overlay is different it's at a different level and it has different vocabulary. I can switch the paper overlay and then I press the level until I get back to level 1 and now this one says and this one says here also when you have a machine that will take so many hundreds of different words, you can use parts of your spaces to have part of a sentence and then you can create whole sentences by sequencing them together. Moving on, the next device we'll take a look at is the AlphaTalker. This is another digitized device meaning that it's just a basically a fancy recording machine. It's set up with 32 locations and has an overlay that's very similar in function to what Susan just demonstrated with the Digivox. It's designed to press the sequences, press the buttons in it and it talks, wake it up here. You'll notice that only some of the lights are lit on the display. That's because the manufacturer of this device is expecting that you're not going to be removing the display and encourages the users and purchasers of this equipment to try and stick with the static display and they do a little bit more interesting things with some of the levels. There's a lot of sequencing that you can take advantage of with the system. You may notice that right now there's a lot of dead area. Only the lit cells are active. If I press anywhere in the center, nothing happens. I don't get the message until I fully complete the sequence. The device is silent. This also lets me have multiple messages under a single cell. So if I want it to be quiet versus scolding you for being too noisy. This device also works extremely well with different types of external switches. Again I'm going to use the head switch we used before. I have to go into the programming features of the device to turn on the option to tell it that it's going to have a single switch in it. Now when I press on the switch it starts doing a row column scanning. The row column scanning starts off. Let's say I want to say the phrase I don't want it to be quiet. So I'm going to wait for the second row to be lit up and that's the first part of my sequence. I'm going to go to the second row again and make my selection. I don't want it to be quiet. And then it goes back into row column scanning mode and it will time out after cycling through a few times. The next thing I'd like to demonstrate is showing electronic head pointing with this device. Because it's also the first device that we've looked at that will work with a head pointer in direct selection. This is basically a high-tech version of what we did earlier with the manual pointing boards and the flashlight. This light pen you'll notice that all of the LEDs are lit now and the light pen response causes them to flash brightly or to be not so bright. And I'll do the same sequence that I just did before. I would like to use the bathroom. Make the first half of the selection. The second half. Finally, one other feature this device supports is what we call auditory fishing or voice prompting. I'm not going to demonstrate that because I could need a completely different overlay, but you can actually have a second much shorter voice cue that lets the person know which cell is highlighted and selected. That means that this device is the first device we've seen an example of that you could work while completely blind. Voice output communication devices come in a variety of formats. This is the walker talker. It's made by the same people that make the alpha talker and it has similar capabilities. However, you're ambulatory, you're walking around. This is a lot easier to carry. All of these more sophisticated devices can be used with sequencing but they don't have to be. This particular device right now is programmed for single hit responses. And then the person would have some other way of showing you how they feel. This is a way. So you could sequence this but you could have whole sentences in for single hits. These systems can get very sophisticated. This is a sample of min-speak. It's 128 characters instead of the many, many thousands that are you've seen on the symbols that we've been using. Those are from a series called the picture communication symbol and there's over 3,000 of them whereas min-speak is limited to 128. The idea is that icons can have multiple meanings. You're able to compress a lot of language into a fixed character set. It has the advantage over a letter-based system and that you only need one or two selections to create a word. Whereas if you're spelling the word out you need five or six. Prankyromic has also gone to great lengths to provide curriculum materials for integrating min-speak into a whole language curriculum. The last device that we're going to show you is called the Dynavox and this device is basically a portable touchscreen computer and it has multiple layers of pictures similar to the way the Dynavox has levels that you have the paper overlays for. This one creates the pictures itself and so you don't have to carry anything extra around with you. You make multiple selections on the screen that you have or you can go to different screens. You can personalize this by the way so that you can either have it so that when you touch each picture it speaks that word or you can have it so that it doesn't speak it until you tell it to speak the whole sentence. That's how I have it set up right now. So I'm going to push some buttons but you're not going to hear anything right away. And then I'm going to push the sentence. This device is also using very high end synthetic speech called deck talk. It's very understandable and it's very personalized because you can pick the voice. Right now we have a male voice, it can have a female voice it can even have a child's voice. All you do is get into the setup program and change it. The biggest drawback of this device is the cost. It's very expensive. It's also very heavy to carry around and a lot of the higher end devices are very heavy. Battery life is also a concern with the larger systems and a lot of times the people who use augmented communication may also use a powered wheelchair. If that's the case we try to set up a system where they can be using their wheelchair battery for power because they have this really great power source that they carry everywhere they go anyway. With the lower end device battery life really isn't that much of an issue they generally have enough charge to last all day and then you charge them overnight and they're ready to go the next day. When communicating with someone who uses a high end augmented communication device you still have to be patient. The user may need to make several selections on their device before the device starts to talk. A dynamic screen system like the Dynavox is probably actually slower to use than say a fixed screen device that uses min-speak and that's because the person has to follow their thoughts and their construction through several different screens. It can be also disconcerting for the communication partner when they have to hear the person go through each word in a sentence one word at a time and they get to hear the words but you need to be respectful to finish the sentence and either signal you by body language or gesture or in the case of the Dynavox to make it speak the whole sentence for you. Sometimes when talking to a person using augmented communication they may not use the correct grammar or the correct word order or their selection of words may be unconventional. You as a listener are going to have to use some assertive listening and ask some questions one at a time to clarify exactly what that person meant particularly if you didn't quite you're not quite sure that you got it. We've had a fair round to show and tell so let us allow us to summarize a little bit. There are many distinguishing features of different types of augmented communication devices but generally those features can be divided into four factors those are the symbol system that's going to be used the access modality feedback and portability The first way in which devices vary is the symbol system it uses. Some devices are going to be very abstract and use letters and words Other devices are going to use the real concrete object or a smaller representational object that can very clearly communicate what it is but the majority of devices like you've seen today use something in between either a picture or an icon an icon is kind of a graphical symbol a picture may be a line drawing or it might even be a photograph. The second major factor is access method Can the operator handle reaching for a single button between a ray of several buttons? Do they need more space between the buttons? Are they going to have to use can they point with a hand? Are they going to need a light pointer? Are they going to have to use an external switch? What kind of specialty switch are they going to have to use? They're using one of these exotic switches Are they going to be able to handle scanning, row column scanning or linear scanning? Can they handle levels? Are they going to need what kind of prompting are they going to need to get them through the scan method? Is it going to have to be auditory or will beeping and clicking do? Feedback is the third major factor When a person makes their selection on the device how is the device going to respond? Is it going to be silent? Is it going to click? Is it going to say something right at that moment? Or is it going to repeat the choice privately into headphones? Does the operation of the device rely on a visual display of some kind that the person has to be able to see? The final factor to consider is portability. A communication wallet may lack sophistication but it's light and easy to take wherever you go. A person may need because of the communication abilities and cognitive abilities, they may need a high tech computerized device but their setting may not allow for that where they're going to try and operate the device. There are a few global factors involved in the use of augmented communication devices and these apply to both low and high tech devices. The device needs to be programmed for the situation the person is in at the time. They only have that vocabulary available when if a person is going to be interviewed by a total stranger, they may not have appropriate vocabulary available unless somebody's taking the time to reprogram their device. Secondly, keep in mind that most people have more than one type of communication system they use. There's almost always a low tech backup system for one of these sophisticated high tech systems and most people also have a very good way to communicate yes and no and the communication partner needs to be aware of this. Finally, you always, always just need to be patient. There is no augmented communication system that approaches the speed and fluidity of speech. So, you need to slow down your thinking. You need to relax. You need to take your time so that you can give the person time to respond. It's just going to take them a while. And when you set up an interview with someone who's going to be using any kind of augmented communication device, you need to schedule enough time for it. I would say that if you have 10 questions you want to ask, you need to leave an hour. As our final parting comments, we'd like to recommend some print resources for you. We understand that this training will be used as part of a train the trainer program. The first print resource is what is AAC by Pranky Romick Company. And it's a very simple, easy to use and inexpensive book that could be provided for all participants in a workshop. The best single print resource we've come across for comparing multiple devices side by side to each other is the 1996 guide from the AI Dupont Institute, Applied Science and Engineering Labs. They're the Rehabilitation Engineering Resource Center that focuses on augmented and alternative communication. And this guide compares about a hundred different devices side by side with statistics and photographs. Finally, we'd like to suggest the very excellent engineering training environments for interactive augmented communication by Pamela S.L. and Carol Goosens. It's recommended as a resource book for independent living centers, supported employment, sheltered workshops, any place where you're dealing with folks that have moderate or severe developmental delay. It includes a companion book that includes overlays that can be used on the different types of augmented communication devices. Basically, they can be Xerox copied and used right out of this book. On behalf of the Maryland Division of Rehabilitation Services and the Maryland Technology Assistance Program, we'd like to thank you for giving us this talk with you. Again, I'm Susan Levy and this is Bruce Bailey. And we hope that our little demonstration has helped you to feel more comfortable in conversing with people who either use picture boards or electronic devices. For more information, you can contact the Vocational Rehabilitation or the Technology Assistance Program in your state. Welcome back. As you can see, there are a lot of different devices that people can use to help themselves to be understood. Again, our point today is to just expose you to some of them to let you know there are additional resources in each state and we encourage you to take advantage of those. So that you will be comfortable when you go out and meet folks. We want to now move to the third part and final part of our presentation. If you do have any questions based on what you've seen so far as I go through, of course, factor them in. We do have some that we will address later. The third part is going to what we call pulling it all together. And basically we have designed a series of exercises. The staff with the ICFMR program here in Baltimore, along with Diane Smith, who's a consultant that worked with us, have designed these. But before I move to those, we want to review a few points that we want you to keep in mind as you go out and start interviewing and talking to folks. And I think you'll see those points on the screen. Basically, the points that we would like you to keep in mind are to take your lead from the person you're interviewing. Pick up cues from them. Listen to them in a way that you don't usually listen. We rely on what we call a familiar other. That's the person like Diane. That is the person who knows the individual and can help you to understand and interpret what it is that they're saying. Sometimes as surveyors, it takes us a long time to figure out how someone communicates. So to move things along which you sometimes have to do in a survey setting depend on that third person. But as Ruth made the point of saying make sure you don't cut out the person you're interviewing. Remember to look at the person and talk to them. Don't talk around them. Don't talk as if they're in the third person. They're there. They're listening. Talk to them. Be sensitive. As surveyors we sometimes get intrusive with our questions and unfortunately we sometimes have to. But we don't needlessly need to invade someone's privacy or get information that we don't really need. So be careful what you need. Ask the kind of questions that you would like to be asked if someone was trying to get this kind of information that you cared for. Be patient. That's the most important thing. Breathe and be patient. Use Diane as a model. You know that Diane knew the answers to some of those questions because we had asked ahead of time. And she and Ruth had worked out the answers. But what she did is she respected Ruth's dignity in taking the time and giving her the time to reconfirm those answers. So be respectful. Technique I use sometimes is simply to breathe deeply. And again I've said that before but let's remember to breathe. And then sometimes if I need to I count slowly in my head. And that keeps me from jumping in impatiently and answering for a person. But instead gives them the respect and time to answer that question themselves. And finally and most important is if you don't know what to do or how to interact or where to sit, ask the person. They'll guide you or the familiar other that's with them will guide you. So keep those points in mind as we move into these exercises. Now what I want to do is walk through a variety of exercises that we sent out with the packet ahead of time. We're not going to do those today but I do encourage you to use them. Finding time to do training is difficult. It's hard to find a whole day, much less a half day. So we encourage you to take these at different times. Maybe use them in a staff meeting, use them at the beginning of a different type of meeting. You can even use them in the car when you're driving between survey sites. Just things to kind of break up the eyes, practice a little bit and have fun with it. We're very serious about what we do but it is important to have fun with what we do. First let me talk about the handouts that we sent to you. There's two. The first handout is basically a summary of some of the basic primary 101 of interviewing people. It's something you can use to review for yourself or introduce a new staff person to who hasn't had the benefit of the training that we have been offering. The second resource is just basically the fundamental tags. The four core conditions from the ICFMR survey protocol and the 52 tags that go with those. As you'll see in the exercises as we move through them, there are times when you may want to refer to those or use those as a resource tool. That's why we've included them. There are now eight exercises that we want to move through. The first one is an icebreaker. Basically the icebreaker as we all know is to kind of get people comfortable. When you are starting a training situation, the fact is you are going to be nervous and the people around you will also be nervous. What we want to stress with this icebreaker is that the people that you are working with will also be nervous and the people that you're going to go interview are going to be very nervous about a surveyor coming in. So what we've tried to put together here is an icebreaker that you can use that kind of gets that point at home but also makes it a little fun. What we basically have done is encouraged you, and there's a couple of ways to do this, but in the exercise as you look at it, you'll see there's a whole list of questions. Some of the questions are things like do you write or speak better? What bugs you most when you're talking to someone? And do you prefer to talk or to listen? There's lots of others. But the idea is to take those, cut them up, and just to have people who are introducing themselves at the beginning of training to pick one. So I would say, hi, I'm Catherine Hayes. I'd pick a question and say, do I prefer to talk or listen and then I would answer that. And you let folks go through that. But once you're done, and hopefully you've had a chance with this, but once you're done, then take a few minutes to discuss what is it that happened while you were doing that? Who was so nervous because they thought they would get asked something they couldn't answer? Who thought they were going to be made a fool of? Who tried to get hold of a question and peek at it beforehand? And who made up their own question and didn't read what was given to them? But the point is that we're all nervous, and we as surveyors need to keep in mind that the people we're going to be interviewing are also going to put people at ease as you go out and interview. What icebreaker works for you? Often I'll just connect with someone by introducing myself, saying where I'm from. I've lived in Texas, so I can talk with a southern accent. There's just different ways that I try to put people at ease, and I share a little bit of information about myself. But each person will have their own way of doing that. But do come up with something that helps to break the ice. Next we have a series of exercises that give you some assistance in from yes, no to open-ended questions. We've talked a lot about those. Yes, no is basically when you ask a person a question that they can answer by nodding or shaking their head saying yes, saying no. Very structured pointed questions. Open-ended questions on the other hand are questions that you want to draw out a response from, something that you want the person to have a chance to respond to. As you go out interviewing folks, what you're going to find is that some people respond better to yes, no questions, and others respond better to open-ended. So instead of you may not know as you walk in which will work best. These exercises are designed to give you the survey or some practice in switching from one format to the other. The way we encourage you to set up this exercise is to take some newsprint and put it up around the room to take that resource number two that we talked about maybe and write some of the standard numbers down, and I would choose standard numbers that people tend to have trouble coming up with questions for. And then basically assign people into groups, small groups, and have them stand by the newsprint. Then what you will do as the trainer is simply say, alright in the next minute I want each group to write a yes-no question for that standard. Then you have people move to the next one and you say, now I want you to write and it can be yes-no again or open-ended. And go through this several times. What you'll end up with is a series of questions for each standard that are phrased either as yes-no or open-ended that people can then use as a resource in the future. Again it's also a good way for getting people up and out of the seat moving around a little bit which is sometimes hard with training. The next exercise number three is called beat the clock. It's very similar to number two but it's something that you can use when you have a very large crowd or a shy crowd people who don't want to get up and interact too much. So instead of having people bond and form teams what you can do is have people sit in their seats you still give the standard number and then you ask them to write a question be it yes-no or open-ended. And after you go through several exercises of this then you can have people call out their answers so that you then again end up with the same product which is a list of different types of questions for the same standards. So that's number three and we just call it beat the clock because again making it fun put some time factor into it use a beeper, a bell and to call the time. Number four is a switcheroo and basically we want to increase your ability and comfort with switching questions, adapting questions as you need to. This one is a much more structured interview and what we've done is we've put together the four core conditions and also the 52 tags and we've given you some areas to start with some questions. The example that I'll use is client protections the core condition of client protection. In the handouts that we gave you there's eight different sheets and for example under the client protections we have this instructions would say following are some yes-no questions that we want you then to write into open-ended questions. So we've already given you a way of structuring it and what you are to do is to ask the trainees to take it to another type to make it into an open-ended. Then you can simply switch over the paper and go the other way open-ended to yes-no. Of course you can switch over the paper to yes-no questions or two but would rather you not do that. One of the questions you might get under tagged standard 124 would be do you know how you got hurt? And that of course might be when you're doing a complaint investigation. Obviously the person could nod yes or no but it would be a place to start but if the person could tell you more and you would want to turn that into an open-ended question you might say tell me about how you got hurt and you could go from there. Do you notice a difference when you don't take your medicine or you could switch it to how do you feel when you take your medicine or have you missed your medicine before what happens when that occurs. But basically it takes a little bit of practice to change back and forth but you're going to need to be able to adapt as you talk to different folks. Okay now we want to switch gears just a little bit and go to a different type of components of interviewing. Basically as you get ready to interview someone ahead of time, you need to give some thought to it I know you've been doing this now for a while and you realize it's not easy, it's hard work. So the next series of exercises are to assist you in setting it up to get some practice and thinking before you go out and talk to the person. We have a series of short exercises again we encourage you, use them at a staff meeting, use them as a break up in between other types of training to give you some practice. As with anything the more you practice this the better you're going to be at it. But in this particular exercise number 5 which is called setting it up we have given you several scenarios such as the person to be interviewed uses a combination of body movements and sounds and that would be very similar to if you met Ruth before she had maybe her communication devices. The trainer will then ask you as participants to write down what would you consider, what concerns what things should you think about prior to getting out to meet the person and interview them. Then we would ask you to think about how do you get that information so you've listed some things that you might have considerations about or concerns about. Where would you go to get that answered would you go to the person would you ask someone around them would you do it through observation through first meeting the person so we want you to give some thought to how you would go about doing that. On this one we have included an answer sheet that US trainers can use to figure out the type of thing that we're looking for. Now for those of you who do like group work number six is basically very similar and it is a group activity setting it up. And basically as I said it is the same exercise but it's a brainstorming exercise and as you know in brainstorming you have fun everybody should say whatever comes to mind and the only rules are that you don't laugh at anybody you just keep flowing. In this one you ask people to observe first about a person before meeting them and that sounds a little funny but basically what we mean is before you interview someone what do you want to observe about that person before you meet them before you sit down and formally interview them. It might be what kind of communication advice do they use would it be better to be someplace where something could be plugged in do you need to be sitting down do you need to have a third person to assist you but the idea is to come up with a group brainstorm and share things that have worked for you. At this point as surveyors I think you've gotten quite a bit of experience with interviewing and it would be important to share with others and also new surveyors who are new to this process the things that have worked for you. The next one number seven is a role play and I know that we've all done quite a bit of experience but basically a role play is a safe way for you to practice before you go out this is particularly good for brand new folks to this process you've been doing this many years and you're very comfortable what you can do in that time then is play the role of the person being interviewed to assist the newer person to get comfortable with interviewing and then you can give them feedback we have designed some specific role plays for you, you have those in your materials we've designed them around some of the standard questions some of them could be fun like around money around what you like to do for fun but we have given you some things to put together and what we encourage you to do is to break into groups of three someone to assume the role of the person being interviewed and it can be the individual served or if you're more comfortable a family member, direct support staff person advocate or guardian then we would encourage that one of you play the role of the interviewer use the sheet that we've given you to do that and a third person to kind of moderate sit, watch, observe who can then give feedback to help to get more comfortable in phrasing questions and getting answers and again it can be fun and finally we come to the last exercise that we have put together for you and it's called the familiar listener now we've talked quite a bit about this but this is the person who understands how someone communicates maybe not everything they're thinking but what they're trying to get out for example if I were to go out and meet someone who took a while to understand it would take me a long time I might not have that time on a survey because I have a lot of things I have to do so instead of putting the burden on that person what I would say is I'm sorry I'm gonna have to have some assistance who would you suggest or how would you suggest I understand you and hopefully we'll have a third person involved who will then help me who understands the person much better it may be that the person speaks an example I've used before is my mother with Huntington's I could understand her when others couldn't it's because I'm around her so in that case I would be the person who would help to understand and interpret the focus however would still be on my mother and that's the important thing I want to emphasize even when you use a third party the person should be there and they should be the focus of the interview that is very important but this whole exercise again is to emphasize that it is okay to get help it is important to plan ahead and it is important to recognize when and what resources you might need I basically found that interviews fall into three categories there are the people I can sit down and interview independently that I understand through whatever means of communication they use and we don't need any other assistance the other folks are folks who rely pretty much on a third person family member advocate guardian and sometimes their direct support staff person to assist but again that person should be the focus of the interview and they should be at the interview and finally there are the people who are understood by someone who knows them that familiar listener but who can essentially answer the question as long as there is someone there to help you understand what they are saying all of those have different needs and different ways that you would set up those interviews it is good to know ahead of time what you are going to be needing so that you can plan ahead and make the best use of your time and also the best use of the time of the people you are taking away and we ask you to make some notes about how you would prepare for an interview with someone who maybe has someone who understands them but you don't and how it would be different to prepare for an interview with someone who maybe is very difficult to understand and they have brand new staff someone who doesn't know them very well how would you prepare for that interview in a different way those are the eight exercises again we have borrowed liberally from other folks as I have encouraged before as training resources make it fun we want to encourage that no matter what you always start with the person who is getting the services that you always involve them in the interview process if you need assistance it is okay to ask for it to make sure that you are not losing the focus on the person and that you have fun with this that you practice and use these exercises like anything else in life the more you do it there is a couple that we had not answered prior to the session and I do want to get to those and we will see if we have any other questions that have come in while I have been talking with you first I want to read a couple of questions that came in one I asked Ruth before she left because it was for Ruth but we had already gone off camera and the question was between living at state school in 1962 and then in 1985 when she moved into an apartment did she live in other living arrangements and what kind of options was she exposed to and basically as I think Ruth shared in her talk and I think she goes into quite a bit more in detail in her book she basically went from the state school to an apartment there were a couple who were running a supported living environment who went and as she said picked up her and some other folks and moved them into the community they then that is where she has been now what she did emphasize is that even though at that point I think you get the picture that Ruth is quite independent and quite outspoken she does help to hire her staff her and her husband have to say on that they interview and they said a lot of the ground rules about how things happen and what kind of assistance and support they get in their home but for Ruth that was quite a transition and that is why you can see that the butterfly is very important to her another question that we have is the ICFMR survey process that is conducted with individuals who live in ICFMR facilities the instructions to surveyors on conducting an interview recommend open-ended questions and that is true in our survey protocol we did put that out but for persons who have a difficult time communicating do we recommend open-ended yes no etc that is a good question and I think the whole purpose of these exercises that we have put together is to acknowledge that yes we put our questions originally together because that is how we tend to think of questions but the fact is many people you are going to interview you may need to go back and forth and that is why we have exercises that give you practice it is switching from open-ended to yes no the whole idea is to get the information you need in the best way possible that sets you up to communicate with the person so as I leave you today I just want to remind you that as Ruth said everyone communicates in some way it is a burden upon us to figure out how and of course they have a burden in trying to communicate with us we need to work together on that and as Kathleen Buckley pointed out keep an open mind we certainly learn a lot that way I want to thank you for being with us I want to thank the staff here with the ICFMR program and Rosa who is with the training department for putting this together and I also want to thank the crew here at HICFA studio which you can't see but I can that have done a wonderful job in working with us and bringing this to you today we encourage you to join us at future broadcast thank you very much for your attention we look forward to seeing you in the future