 we are now being recorded, which I know a lot of people are keen to have happened. So welcome, my name is Kathy Howry. I am not actually Roy McConnell, as it says, but I'm Kathy Howry and I'm here today on behalf of the Provincial Low Incidents Team of the Regional Collaborative Service Delivery. And also online is my colleague, Wendy Qua. So Wendy and I are delighted to have Marianne Romsky and Rose Seppkeck. And Rose, I'm always afraid that I'm butchering your name, so forgive me if I don't say it correctly. I need to practice. These two professors are eminent scholars in the area of AAC and they are both from the University of Georgia. Dr. Seppkeck is a distinguished professor in the Department of Psychology at the University of Georgia. Dr. Romsky is a Regents Professor in Communication, Psychology, Communication Disorders and is the Dean for Research and Graduate Studies or at least as it says in the book, I'm not sure if you are, continue to be Dean, but they both have, keep out of trouble. They, with being very busy, they are both affiliated with the Center for Research on a Typical Development. They are both active in the world of writing publications, books and chapters. And as I alluded to, I'm gonna put my camera on. This is one of the most recent books that I purchased from them, which I highly recommend, Communication Interventions for Individuals with Severe Disabilities, Exploring Research Challenges and Opportunities. And then as any of you who know me might know, this is perhaps my favorite book of all time in terms of AAC, Breaking the Speech Barrier, Language Developments, Regmented Means, and this is Romkin Zepchak from 1996, I believe. I think that's what you guys can, yep, 1996. So that's the end of me on the camera. They are both, as I said, preeminent scholars. They are Asha Fellows, Isaac Fellows, AIDD Fellows, members of the National Joint Committee for Communication for People with Significant Disabilities. We've had some people on our webinars that talked about that before and they are definitely widely known and internationally respected. I had the wonderful pleasure. I don't want to talk too much about this, but I have to talk to my community. So I have to talk a little bit about this. What's your name? What's your name? I don't know. I'm gonna answer my question there. Thank you. I had the pleasure of meeting Marianne and Rose at Isaac in Toronto in 2016 and attending their workshop on the AAC myths. And again, as many of you will know, they are the original AAC myth ladies. So I could talk about them all day, but that would take too much of the time away from their wonderful talk, which I'm very excited about because this is the first time that we've really touched on toddlers and really early intervention. And as I hope you all know, the original collaborative service delivery mandate is to serve kids zero to 20. So we're finally getting down to some of the younger ones. And with no further ado, I would like to turn it over to our presenters today. I'm very excited. Thank you for coming. Kathy, this is Rose Stepchick. Welcome to everyone. Thank you so much for that generous introduction. Marianne and I are pleased to try and share some of the work that we've done over the years. So as you've set us up, we're gonna plunge right in on the very first image that you see. We feel the need to make sure that you have a notion about any disclosures that need to be made. And you can see we are declaring both in the financial and non-financial realms. And we'll leave that for your perusal and move on to the learning objectives for this afternoon's session. So we wanna try to tackle several specific objectives. First of all, we want to examine the role of receptive and expressive language skills in the early language intervention process. And we want to focus on the importance of speech generating devices in what we like to call augmented language interventions. We will describe parents' role in augmented language interventions that we've designed and conducted. And talk about the protocols that we've used in those parent-coach language interventions. We'll also spend a bit of time talking about the transition from the early intervention period to preschool and underscore and articulate the role of augmented language intervention in the development of speech. So let me continue the introduction to our session today and kind of lay out our sort of approach, if you will. And as you can see, we wanna declare AAC, augmentative and alternative communication as an intervention approach. When you think about AAC, I know I'm preaching to the choir here, but feel the need just to touch base to make sure we're all talking about the same thing. We're really talking about all forms of communication that are available. And typically you have two sort of large categories, unaided and aided. And in the image before you, you'll see that unaided forms of communication include simple gestures, facial expressions, manual signs, and sign language in various forms. Aided forms of communication and contrast are picture communication boards, dedicated computer devices that actually speak words and sentences for its users and this can range from computer tablets and smartphones. So if we talk a little bit more about the early language intervention process in AAC, we're really talking about individuals, children for whom these significant delays in communication development are actually impacting all aspects and phases of a child's overall development. The accident intervention research has typically focused on developing spoken language skills or on teaching so-called pre-linguistic skills. And though of course we know that our collective goal is to develop functional, intelligible spoken language if possible, approaches that focus exclusively on speech can often frustrate the child and his or her family members. And we also know that even with the establishment of a pre-linguistic base of skills, a child with a severe communication disorder may not make that transition to spoken language. So we view early augmented language experience as facilitating all forms of communication, including speech. So Kathy already gave a little bit of an advanced preview here but as she mentioned, Marianne and I have talked about several of the myths that we will actually provide in a sense kind of barriers towards achieving early intervention using AAC. So we've identified some of them on the screen in front of you. In myth one, we often have experience as perhaps you have, the view that AAC is really a last resort to be tried in intervention. We'd like to have people recast that as perhaps the first line of intervention, the first line of defense for children and their families as they're developing their speech and language skills. Myth two is certainly one that we likely collectively have heard more than once. That is that AAC would hinder or stop further speech development. Certainly our own work and the work of other investigators have put to rest this myth. Myth three sometimes surfaces in the sense that speech generating devices may be considered only for children who have intact cognitive skills. Our work in that of many others indicates that those kinds of cognitive barriers, if you will, are simply that barriers that people have imposed. Myth four that we've identified here is that individuals must be of a certain age in order to benefit from AAC. Kathy made reference to one of our first book volumes Breaking the Speech Barrier. And in that particular study, the mean chronological age of the participants was 12 years plus. So we can show that well beyond the period of time chronologically that one would expect to see gains, including gains in speech can be accomplished if youngsters have appropriate experience. So age should not be a barrier as well. And finally, and you'll hear more about this as we progress in the webinar today, that parents simply have difficulty using speech generating devices so we can't have them be involved in that. So in this clinical research program that will detail in the rest of our hour today, we note that we have been funded by the United States National Institutes of Health, specifically the Institute that focuses on deafness and other communication disorders, and also the Institute of Education Sciences. For successful programs, as I know you know, because of the environment that you work in, it literally takes a village and several of the people who have worked with us are identified on this screen. So let's talk about the early language intervention studies that we're gonna underscore for you today. We're basically going to be talking about two main studies. In study one, we examined the effects of three parent implemented language interventions. One that focused exclusively on spoken language skills and two that had forms of augmented language skills on the development of vocabulary learning, both in the spoken domain and the augmented domain for 62 toddlers and their parents. The toddlers were perhaps not surprisingly 24 to 36 months of age chronologically. We'll also talk about study two, where we attempted to study more about the effects of intervention and the pieces that are most effective in producing communication outcomes. And here we compared the effects of two parent implemented augmented language interventions. Again, looking at toddlers, spoken and augmented language learning. In this study, 51 toddlers participated as well as their parents. And again, they were 24 to 36 months of age. So let's talk a little bit more. The intervention that we have designed and conducted these studies with, you see the chronological age and I've mentioned it but let's talk about more characteristics of the participating toddlers. So for youngsters to participate in this study, they had a vocabulary of at most 10 intelligible words. Using the Mullen scales of early learning, they would have produced the score of less than 12 months on its expressive language scale. The toddlers would need to demonstrate at least some form of primitive and intentional communication ability. And they also needed to have upper extremity gross motor skills that allowed them to select the symbols on the speech generating device. These youngsters had a primary disability other than delayed speech or language impairment or deafness or hearing impairment. And if we combine the total number of participants from study one and study two, we're talking about 113 toddlers in these two studies. So what questions were we interested in? What questions were we trying to ask? The first one actually evokes a little bit of that myth that we have been working on knocking down. Namely, can parents and interventionists implement these types of interventions? And importantly, when parents are implementing them, does it result in child language gains? So now we're going to detail aspects of the intervention as we carried it out. The intervention framework focused on both input and output strategies. And they always occurred within naturalistic teaching routines. We want to note that in study one, as I had alluded to earlier, we had one condition where it was a spoken intervention only. So by that we mean no use of a speech generating device, simply using spoken language. We followed a specific parent coaching protocol and it included observation, parent coaching during intervention, and then transfer to the home communication environment. The details of each of these intervention types across the two studies are going to be detailed by my colleague, Marianne Romsky. And so I will turn over the range of this webinar to her. Marianne, thanks Rose. Hi everyone. So Rose said that we have two studies and what you see here in this particular slide is the different interventions that were used in both studies. SCI is the spoken intervention alone. You can see that that has no use of a speech generating device. ACI was augmented communication input and that approach used a speech generating device to provide communication input to the child, but the child was not required to produce symbols on the device. But the symbols were available to the child and if they did use it, they were reinforced appropriately for their use. In ACO, which you'll see was used in both study one and study two, the child uses the SGD to communicate and the interventionist and the parent, INP, encourages and prompts the child to produce communication using the device. Used only in study two and you'll see why this is the case as we talk about the findings from each of the studies. Is ACIO, which is a hybrid intervention combining input and output. And this is for Kathy, going back to breaking the speech barrier, ACIO is really the sal from the old breaking the speech barrier book. ACIO combines input and output. So the interventionist and the parent model of vocabulary for the child using the device symbols are positioned in the environment and they also encourage and prompt the child to use the device. So those are the four different variations of intervention. One of them used in study one alone is spoken only and that's used as a contrast to the augmentation and you'll see why that's really important as we talk about the findings. And then ACIO, ACI and ACO used in study one. So those are three interventions in study one and then in study two and overlap ACO with ACIO. So no matter what intervention the child was in the intervention protocol was comparable. It was 12 weeks or 24 sessions which you'll also note is a relatively focused period of time. Nine weeks or 18 sessions occurred in our lab, families came to the lab for the intervention and then three weeks, the last six sessions were generalization to the child's home. So we brought the intervention home which is where it would be used for the majority of time after the protocol was completed. All sessions were 30 minutes a piece and they would divide it into three 10 minute blocks of three activities, play, book reading and snack. And that was that what we wanted activities that would focus on... Yeah, I'm not sure if you know what to do with this game. Hello. You can switch. Sure, I'll tell you guys a little bit about this one. Thank you so much. Thank you. Can you please mute? No, thank you. Okay, if somebody's going to pass a big word from me to you please, we'll see you in a minute. Thank you. Thank you. Okay, I think we're back. So back to the 30 minute sessions. There were three 10 minute blocks of play, book reading and snack. And that was so that it would mimic, so to speak, activities that parents would typically do with their child at home. It could also expand to mealtime activities beyond snack. But those were the three 10 minute blocks that we had. And there was an individualized vocabulary for each activity. The parent training focus was set up that the first four weeks or eight sessions of intervention, the parent observed with the speech language pathologist in the adjoining observation room. And you'll see a photograph of that shortly. The parent had a protocol manual with weekly materials that they received from us. You'll also see that. And beginning in the fifth week, parents backed into the session with ongoing coaching by the interventionist. The three 10 minute blocks did not vary. They were always play, book reading and snack. And the backing in always went snack, book reading, play for the parent. And that was so the parent didn't have to leave after the snack activity. Beginning in the eighth week, the parent led the session and was the main implementer. The target vocabulary selection. So prior to the first session, the speech language pathologist and the parent worked together to choose target vocabulary. We chose six target words for each context, play book reading and snack, with a combination of nouns and core vocabulary, core being my turn, all done, more, what's this. There was an overlap of core vocabulary across each context. And quite importantly for our results, the child did not comprehend or produce the target vocabulary word prior to the intervention. And then we used Mayor Johnson, boardmaker symbols to represent the target vocabulary. We had measures of target vocabulary development, which was the key variable that we were interested in seeing whether there was change in. And we did that with transcripts of the intervention sessions. And target vocabulary use was coded to quantify its use in terms of number of target vocabulary words used spontaneously. And that was critical to what you'll see at the end. These are all spontaneous use by the child. The mode of communication used by the child when we looked at the transcripts for expressing the target vocabulary word, it was coded either as an augmented word, meaning it was a symbol use, a spoken word that the child produced it, or they produced the spoken word and they used the augmented word. The intervention strategies we used during the sessions were creating communication opportunities. And these are all things that many people use in intervention sessions. And we used a range of them with children. One, provide choice for the child. And these were the things we were teaching the parents to do, create communication opportunities and communicate with the child. So creating opportunities, provide choices, sabotaging the environment, giving small amounts so the child would have to make more requests, briefly delaying access, using pause time and using fill in the blank activities. In terms of communicating with the child, we looked at using parallel talk, using short simple sentences, limiting questions, using key words, slowing their rate of speech, immediately responding to the child's communication attempt, following the child's lead and most importantly, having fun with the child, making it a positive experience. In terms of the parent coaching, let's talk just a little bit about the things we did with our parents. First of all, we kept a very positive attitude with our parents. We were not negative with them of things they couldn't do or didn't do at the start. We presented information in a manner that fits the parent's learning style. So we did verbal and or written feedback. We did demonstration and modeling and at the end of sessions, we did videotape review. We gave specific and concrete examples of what things a parent could do. We built feedback around what was needed most to support the child's progress and have the parent be able to implement the intervention with the child. We followed a consistent format at the end of each session when we were reviewing the session. We asked the parents what they thought about the session. We gave positive feedback first. We identified and gave feedback in primary areas of needed support and then identified and gave feedback on secondary areas if it was needed and warranted. We asked the parent if they had questions and then we summarized with positive comments and we did that for every session so that the parent knew what the, they also knew what the routine was as they were going through it. And the areas in which we provided coaching were creating a context for conversation, how the many protocol itself, how we did it with the child in the 30 minutes that we did the 10 minutes and 10 minutes and 10 minutes. We actually used a timer that went off so that the parents knew when 10 minutes were up so they could switch the activity. We talked about modeling language. We talked about the ability to create communication opportunities both in choice making or setting up the environment. We talked about the child's performance. We also talked about behavior management issues, how you might redirect or motivate the child, deal with transitions that might be difficult for a child. And then we also discussed interaction style, for example, directive or passive in terms of how the parent was interacting with the child. And we provided coaching in those various areas which varied slightly across parents but those were all the areas we worked in. And here you can see a picture of a parent working with the speech language pathologist that happens to be Andrea Barton Halsey. And then through the window behind, you see our interventionist working with the child. So this also gives you some examples of the weekly goals we set. Every week the parent got a paper to add to a binder that we had that focused on what the goals were for the week. And here you can see it's week five and this is in the ACIO condition. They had child targets, parent targets, interventionist targets and then a look ahead for what the following week would look like for them. And we had this for each type of the four different interventions and the parent received this and then kept it so they had it for the week going forward. We gave, this is an example of some of the individualized written feedback. Again, this is for the ACIO condition and it talks about what the parent had done, what they did well, how they did it and gave them some ideas for future directions. So that they had something to take away with them. One thing we didn't say was in the beginning was that one reason why we started in our lab and then went home was in some of our pilot work, our parents felt very strongly that it was very difficult for them to implement the intervention starting at home, that there were too many things like other little kids tugging at their legs, the phone ringing, somebody asked another child asking for help and so when they came to the lab we provided childcare for the family so if they brought another child with them, somebody was taking care of the child so that they could focus their attention on observing their child at first and then moving into the intervention sessions and really focus on that and our feedback from the parents was that that was very helpful to them and that when we did take it home they already knew what they were doing and how they were doing it and so it was more about transitioning to home rather than starting out. So I'm gonna talk just briefly about the clinical research outcome from the study and Rose talked about what our questions were so first question is can parents implement these interventions and parents with at least a high school education were able to implement the features of the intervention to which they were assigned and it was implementing the augmented interventions was no more difficult than implementing the oral language intervention. Parents appeared to implement all interventions equally well so regardless of which condition which group they were assigned to they were able to implement the intervention and all the pieces of it. Now probably the most important thing is this parent implementation result in child language gains and the answer is a resounding yes and the children showed gains in target vocabulary use as a managed and spoken word but there were differences across the conditions. I'm gonna talk briefly about the findings in study one in study one ACI and ACO provided a way for the child to communicate via the visual graphic symbols and digitized words after only nine weeks of intervention so that's 18 sessions and remember that these are children with pretty significant disabilities all with less than 10 spoken words most with no spoken words to start ACIO and to a much lesser extent ACI were interventions that substantially increased the likelihood that the children with these profiles would produce spoken words after nine weeks of parent implemented intervention as opposed to the spoken condition alone. So what we found was that the augmented output condition was better than the augmented input condition which was actually not what we hypothesized but that's another story and both of them were better than spoken intervention alone and the use of the SGD contributed positively to the intelligibility of child communication so the children in the augmented conditions in study one did far better in terms of target vocabulary use spontaneous target vocabulary use than the children in the spoken language condition and I'm gonna show you a graph in a little bit from both studies that will show you just how much difference it's quite striking. In study two, what we did was take ACO which was the output condition and the best condition in study one and compare it to a hybrid which combined ACO and ACI together so that's why we have ACIO and we did that because even though ACI wasn't as strong as ACO it was still much better than spoken alone and so ACIO in some sense not surprisingly the hybrid provided the strongest use of augmented and spoken words so pulling it together was really what gave the best outcomes for the child in terms of vocabulary acquisition and we also included in study two something that we called a weightless control and that was where children half of the children started immediately when they came into the project and half of them waited three months before they started which was the length of the intervention and what we found is that if they during that three month period they did not develop expressive communication skills so we feel comfortable saying that they don't develop the skills without intervention and the other issue in study two that comes out is that the role of receptive language skills at the onset of intervention probably needs some more attention and that's something we're working on right now and this next slide is a figure that shows you the vocabulary functional vocabulary size so children learned up to you'll see the graphic goes from zero to 20 vocabulary items and on the left side of the screen is spoken communication and you can see that children on average learned one word if you look at ACO if we read left to right ACO in study one they learned 15 vocabulary words and you can see if you look down on each bar the top part is spoken only the middle part of the bar is both spoken and augmented and the lower part of the bar is augmented only in ACO in study two almost as good as what it was in study one and ACI you can see still much, much better than spoken alone but none of them as good as spoke as ACIO which is the combination that gets you almost to 20 symbols vocabulary words that the children are learning so that gives you the sense of what they learned through the study and it compares both studies so total you're looking at 113 children response to the intervention I'm going to talk just briefly about clinical implications, clinical applications of this and talk just about some strategies that we think are important based on what we've learned and what others in the literature speak about one, we are really strong proponents of beginning AC intervention early and to integrate AC strategies into early language intervention as opposed to using AC as a last resort we began the early intervention work after one of the parents in our earlier sal study said to us about her 19 year old son if I knew he could do this when he was two I would have treated him differently and it really spoke to us about the need to begin early and this parent encouraged us strongly to work with very young children and try to look at what changes could be made when you started early the second thing here is integrating AC intervention into natural settings using existing routines and activities using the child's own toys and books and other motivating items for them so that it isn't a pull out kind of model where children are taking out of the routine but really trying to keep those routines as an anchoring point for adding in the intervention and some more general early interventionist like Julianne Woods has talked about routines and the use of routines in intervention providing training and education to communication partners acknowledging families preexisting values their perspectives and their experiences that they bring and really trying to work with how they view things and what they're doing as they move through an intervention considering individual learning styles and providing feedback appropriately really looking at how the children as well as the parents are learning and looking at what kind of feedback is most helpful to them individualizing services and supports making individual decisions regarding vocabulary for each child and choosing activities and materials that motivate and interest the child and then integrating AC within systematic language based instruction and we really see the use of speech generating device as a tool within language intervention and really using routines and functional environments to build language skills using the AAC tool selecting relevant vocabulary considering the child's motivation as well as family routines and developmental appropriateness and also then thinking about number and arrangement of vocabulary and word types and those are a range of issues that start to get more complicated as the child begins to develop more vocabulary words and one that's really important to us is allowing ample time for intervention success not giving up too soon consistently implementing the same strategies week after week and documenting progress over time sometimes you have children who sort of get it right away and figure out that this symbol goes with this spoken word and other children need time before they get there and sometimes I think we all too often switch to a new activity or a new strategy before we give a strategy time to succeed and looking at how much time a child needs to be able to get there and it's different for every child then monitoring AAC intervention programs over time establishing formal and informal ways of gaining information from family members such as journals, emails, teleconferences even thinking of web-based ways that might be able to go back and forth to monitor progress and monitor provide support to a family and adding new vocabulary as needed over time so the issue that then we came to as we were dealing with young children who were in the United States in early intervention and in the States early intervention goes zero to three and at three they transition to preschool so our intervention was really set up so that we got them when they were in early intervention in Georgia it's called babies can't wait and then they transition to preschool which was now a different service delivery system and different professionals working within that system and this was a real challenge for us we think the same intervention principle should apply when you transition to preschool you should use a consistent AAC intervention strategy overlay it with consistent language and communication strategies provide choices, provide modeling, give pause time, add individualized vocabulary for the child and now there would be new vocabulary for a preschool environment and again use the device during consistent routines and really the biggest difficulty and the biggest hurdle for us was training and educating these new communication partners it was no longer just the parents but the teachers and the SLPs and the teachers aid and the bus driver and all the other people who were involved with the child we often faced SLPs which distress me greatly and teachers who would say no that child can't do that you could just do it with them cause it was research and that would be very frustrating for us so one thing we're very focused on is trying to figure out how to get the preschool teachers more in line with what's happening in early intervention but we think the same kind of strategies apply you might change the routines and change the vocabulary but you're still gonna be providing the same kind of activities and language-based strategies that you would in early intervention and I would say this we're still working on this preschool transition stuff let me summarize and then we'll have a few minutes for questions children between the ages of two and three clearly can benefit from a systematic AAC parent coach language intervention model parents play a critical role in their child's communication development and especially if they're given systematic coaching and support to help them as they try to develop the best strategies for use with their child I think the next comment here is one that and Rose talked about when she was talking about myths and we talked about in terms of the data that we have but AAC does not hinder speech development in fact our data strongly suggests that it helps speech development and in fact it probably helps it more than focuses that are on speech alone or oral language alone so we feel very strongly that the whole idea that the myth of you shouldn't do this because it's going to hinder speech is definitely not true for young children and our data clearly support that the next is the importance of not just the expressive language but also receptive language to AAC intervention and here this is an area where we are really focused on working moving forward we really are looking to try to distinguish different strategies whether that ACI strategy might be better for children who are very low comprehenders to begin with and that they might do even better with a strategy that starts out with input and goes to output so sequenced but we're working on that right now and trying to look at that but we really think that receptive language is a very important part of early AAC intervention we also think that the components of this framework may be used broadly in a variety of clinical and home-based settings so that there's applicability to a wide range of uses and we say thank you for listening to us as we went through this and we're happy to take questions or talk more about some of the study so thank you. Thank you, Mary Ann Amarillo, that was wonderful I'm now writing down some notes and it's lovely to see Thal re-invented and stronger than ever so there have been a few questions that have been posted so I will speak to those first I do have some thoughts as well but so or some things that I want to ask you from one question is about your symbol layout what type of symbol layout do you use? Core with fringe, I think you talked about that a little bit but maybe you could address it a little bit more specifically and did you address the number of symbols available based on the child or was it pretty consistent for every child like your cross children? So the symbol layout was so when these studies were both conducted it was before and you could see that in some of the photographs before we had iPads so they were not dynamic displays so we had symbols up for each routine we basically had a page for each routine and we had a mix of core vocabulary that went across the three activities and then vocabulary specific to the activities the core vocabulary items always appeared in the same location we did not move symbols around during the intervention and number of symbols that was the second part I was trying to remember what it was so in terms of the number of symbols we started out with a consistent number for everybody and that was about 16 symbols that they had and across the three routines but some children learned those symbols and used them spontaneously very quickly and so if the child demonstrated spontaneous use over multiple sessions we added symbols so in the end I'd have to go back to the original paper the JSLHR paper but there was a range of number of symbols that were on the device at the end of the 12 weeks even though they all started with the same number at the beginning. Okay so I'm going to then sort of do a follow-up question to this question before I go to the next one that's in the chat because you alluded to the idea that this is before iPads and one of the things that comes up a lot is that people say oh they're not ready for you're overwhelming them with symbols if you give them what sort of I guess is called in quotes a robust language system given the iPad world that we're in now do you want to comment on would you do it differently would you give them something that had a more robust prepackaged language system or would you still keep it relatively small number of word symbols going in? I think we would keep it as a small number of symbols going in. I think that clearly some children moved on to have more symbols but I think it would depend on the routine I wouldn't put more on there given these children who are at the very very beginning stages of language development of word development I would not go with more symbols at the beginning I would build slowly. Interesting. But I wouldn't build with one symbol only because the other thing we found in other studies we've done has been that you need a set of mixed set of symbols not just nouns to really give the child an opportunity to perhaps enhance their language development as they moved along. Interesting. Good. We would also mix up we would also give a range of type of word on the display. So not just noun boards that we used to? No. Yeah, Kathy back in the day when we stuck to the point addables because we thought okay we know how to handle that most importantly we know how to assess it we do not see spontaneous combinatorial symbol use until we had different classes of words and then it just popped right out as if the kids were waiting to do it but we weren't smart enough because we were so busy being conservative in terms of what we could assess and do. Interesting. So that's lovely. That's a lovely quote. I may wanna and other people on this may wanna talk to you more about restricting symbols I have some thoughts but I have there's more questions here so I wanna make sure that I honor people. People ask lots of questions. So this has been a very positive a very positive talk cause you've got lots of thoughts coming. So one is I think a little bit easy. Any parent friendly resources or websites for parents who need encouragement to use AAC to reassure them that he does not handle speech development maybe your little paper that's out there in the world. The only website that I can think of that they could go to is the NJC website. So we don't have a website that talks about this though we probably should and it probably should be on our list of things to do but the NJC website talks about this issue specifically under some questions and areas for discussion that would be really good. It's a user friendly site. It would be very user friendly for parents and it is www.asha.org NJC. Right and I'll send that out to everyone as well. Okay, great. We did have Amy Goldman talk to your collective wonderful work on the new communication bill of rights. So you have had a few pointers in that direction but I'll make sure that everyone gets and that's a great idea but I also do love the idea that you might add that in your spare time to your own website. A great idea. All right, next question for children who do try to talk but have very low intelligibility I can see that AAC and speech support would work well jointly. Would you choose only AAC vocabulary that the child cannot, and they sort of put it in quotes, say intelligibly, like that intelligibly? It's a really good question. So our kids weren't like that but we have some other experience with the pilot work to this work that we did. We had a little preschooler who started using the device and then became intelligible, had spoken words that were intelligible and basically she stopped using the symbols for those words. Interesting. And what we did was add new words that she didn't say and she wound up having a lot of single word vocabulary and we then used the device to help her combine words and get combinatorial utterances and as she did that, then we reduced the use. So I would say that if they have a spoken word that is intelligible, they probably don't need to use the device for it and it could be used to give them support for work that they're not producing. I think the other thing we're gonna say something. No, I was just gonna say, I think it sounds like a really good strategy. We're being careful in what we say because we have not tested that out but it sounds very reasonable of support some, let the other ones go and I would anticipate that as Marianne's saying, as the youngster makes further progress, you're kind of boosting the vocabulary using that approach. Yeah, and I think the other thing is, I think there are some, I've heard some other people out there talking about how you should combine combining an approach to get better intelligibility with AAC and one of the things that we saw, this is not in the cobbler work but with our cell work from a number of years ago now, that one of the things the device did was give the child a consistent model of how the word was produced and that helped the child be able to say the word. So there really could be some interesting work on how to combine those two things. And I think it's a great way to think about it and it's a really good use of AAC as well. AAC doesn't have, it is augmentative and alternative, or alternative and augmentative, just not just one, it's not just an alternative. It has many uses and for very young children or children just starting out speaking, it could have that use. And our view has always been that speech is very special and it is a amazing form of communication and of course you would want every child to be able to talk. But so if you can get more spoken communication then by using AAC, that's a great additional use of AAC. Absolutely, absolutely. There's a few more questions here. I know it's 4.30, so I do wanna honor your time. Are you up for a couple more? Sure, sure. Wonderful, okay. So this one I think is quite important. It was asked, did you run any groups with multiple children, interventionists and parents or was it always one family at a time? We always saw one family at a time. We did not run it with groups. That would be very interesting to do. We did have groups of the parents come together to meet with us when they finished their participation in the study. But it was a one family at a time study. All right, great. And I agree with you. I think it would be interesting to see how it might be adapted. Maybe this will be a point that I'm gonna say to those on our session today that might not be working exclusively with families. I mean, everyone is working with families but a big takeaway that I had from today's talk was how wonderful it would be. And you alluded to doing this with preschool teachers but so many of our kids in Alberta, their primary intermediary in school is an educational assistant for our paraprofessional and I can't help but think how wonderful if we could do some, I'm gonna call it front end loading with this kind of an approach to education assistants wouldn't our kids have so much more likely for their success in school? That's a great adaptation of this because you also could do it in a way that would be, it's a limited intervention in that it's not a forever ongoing kind of, I mean, you would move to some other piece to it. So you could do a training like that and we clearly show that our families could use this. So I think that would be a great idea. We'd always had the idea of taking the preschool piece and adapting it and doing another, we were talking about writing another grant that would let us do that in preschools but doing it with educational aids as the people you're training would be terrific. You might have to talk more. I mean, and I can hear people's argument oh, that it would take too much time but I also wanna really reiterate, that's time that our kids never get back if we don't. Well, it's not really, overall it's really not that much time. If you think it's 24 sessions, 30 minutes each, that's 12 hours. Yeah, it's a pittance of time really. Yeah, it's not that much. And Kathy, you may recall in the original self study, we did teach all of the teachers of the youngsters who were participating and that extended into school. We did everyone who was in the vicinity including people like the school bus drivers. Right. Well, I know it can be done and actually, as Marianne is saying, with what seems like a more streamlined approach with the toddlers seems very doable. I would add one other thing that this is a going off and it's something we didn't talk about today but we are working right now and are just about finished with it out of the toddler protocols and the things we did with parent coaching. We have developed an app that we're getting set to test in South Africa where caregivers and parents don't, they get the child with neurodevelopmental disorders it's 30 minutes of therapy a month at a tertiary care hospital. And what we've done is take the protocol and create basically 12 weeks of protocol for a tablet-based app that they will use. And the app is just about ready and we're just about ready to test it with a group of children and a control group. And we think this has a more broad applicability and an educational aid could listen to it too. It's also based on routines and you'd have to switch the routines. We have sort of home routines like dressing and bathing and eating and play but you could have school routines as the routine. Anyway, it's in the side but it's something that we're working on that would do that kind of thing. Well, that sounds very wonderful. You'll do it for Africa and for Alberta. So that would be thank you. Okay, there we go. Wonderful, I'm going to, there's a couple of other questions left but I think one of the things that I'm gonna do just to close it up because I think you addressed most of them, is I'm gonna pop over and I'm gonna share my screen. And I'm going to remind folks, oops, not that. I'm gonna remind folks here that are present that we have the wonderful, oopsie, what am I doing here? Kathy doesn't even know how to run this. But we have the wonderful opportunity of having Marianne and Rose come to Alberta in May. So if you like what you've heard here this afternoon and I certainly have, I continue to be, I told them that I was a bit of a groupie when I saw them in Toronto, I continue to be. We will be having, they will be joining us live face to face in Edmonton on May 18th at the university and that's sort of a partnership with the U of A and we're really delighted about that. If you want to register for that, you can go to the Edmonton Regional Learning Consortium. It's $50 for the day, it's a bargain and you'll get fed on top of that. And if you happen to be in the southern part of the province, Edmonton is really sort of the middle part. After the long weekend, they will be in Calgary on May 22nd at the Children's Hospital. Again, thank you very much. Shout out to the Children's Hospital for providing space and again, talking about young children and we threw the breaking the speech barrier in their presentation because that's ultimately I think where, what this is all going to. So I just wanted to make sure that people were aware. I will send out more information to everyone, including some of the things that we promised today. And I just want to say again, thank you so very much for your wonderful talk. It was most insightful and I think hopeful. I am struck by your quote that you said about the family name or the parent that said, if I knew that he could do this when he was two, I would have treated him differently. That almost makes me cry. For us to help parents and teachers and siblings and everyone see kids differently by providing them with a voice in the world, I think is absolutely tremendous work. So thank you, thank you. Thanks for you for the wonderful hour and I look so forward to seeing you in May. And I promise this, well, I'm just going to say I promise that snow will be gone. I will never promise that it will be gone. Well, we hope the snow is gone, but we're looking forward to it and we appreciate the opportunity to talk about what we talked about here and we'll have more to say when we come to Alberta. Wonderful. Thank you so much and thank you to everyone who attended. We will have this up in a couple of weeks if you want to watch the game and I know I will. And with that, we're going to let these ladies go. It's getting a little bit late in their day and thank you again and we will talk soon. Great, thank you. Thank you all. Thank you, everyone. Bye. Bye.