The influence of classroom context on AAC device use for nonspeaking school-aged autistic children.

Purpose: Language learning, including on a speech-generating device (SGD), relies on having communication opportunities to use language. Yet, children who use SGDs do not consistently use their devices throughout the day. As a first step towards increasing device use, it is important to determine how the numerous contexts (e.g. recess, lunch, academic) that exist throughout the school day impact the frequency and type of communication opportunities that children have. Within this study, we used complex adaptive systems theory to investigate whether there were differences in how frequently nonspeaking autistic children classified as emerging communicators (i.e. children who do not consistently produce two-word utterances independently and do not communicate for a variety of communicative functions) used their SGDs to communicate and the type of communication they produced (i.e. spontaneous, prompted, or imitation) across different classroom contexts.Method: Fourteen autistic children who use an SGD as their primary mode of communication were videotaped up to nine times throughout different school days. The videos were coded for the type of device use (i.e. whether the child's use of the device was spontaneous, prompted, or imitation) and classroom context, which were categorised by the inherent level of support and directiveness.Result: There was a significant difference in SGD use across classroom contexts. Overall, the children communicated more and engaged in more spontaneous, prompted, and imitated communication in classroom contexts with high levels of structure (e.g. tabletop work) compared to contexts with low levels of structure and directiveness (e.g. free play).Conclusion: This study highlights the need to increase communication opportunities across all school contexts. Creating appropriate communication opportunities in all contexts, especially those with less structure, will help ensure that communication does not become context-bound.

Systematic Physical Assistance During Intervention for People Who Use High-Tech Augmentative and Alternative Communication Systems: The Importance of Using a Common Vocabulary.

PURPOSE: Speech-language pathologists (SLPs) use prompting hierarchies to facilitate learning and monitor treatment progress. When working with people who use augmentative and alternative communication (AAC), SLPs typically use physical assistance to prompt motor learning. However, there is currently no standardization regarding the number of physical prompting levels or an operational definition for each prompting level. Clinicians and researchers may be working from different definitions; making treatment progress monitoring and intervention effectiveness comparisons across research studies is problematic. METHOD: The purpose of this article is to illustrate the advantage of using the language in the Functional Independence MeasureSM (FIM; Deutsch et al., 1996) to describe the level of physical assistance provided during AAC intervention and AAC intervention research for individuals who use high-tech AAC systems. RESULTS: Standardizing the level of physical assistance will provide important information regarding AAC learning that researchers may use as they continue to study the active ingredients of AAC intervention. Furthermore, standardizing the descriptions of physical assistance levels will enable clinicians to accurately describe a learner's performance. CONCLUSION: This article describes how the language used in the FIM may be used by SLPs to provide a consistent, continuous, and systematic approach to fading the physical assistance used during AAC intervention to ultimately support independent use of high-tech AAC systems.

Within arm's reach: The role of proximity in speech generating device use of ambulatory children with autism.

Purpose: Augmentative and Alternative Communication (AAC) provides an alternative means of communication for individuals who are unable to effectively communicate using spoken language. The present study seeks to investigate the role of proximity in facilitating AAC (specifically Speech Generating Devices; SGD) use in a homogeneous population: ambulatory school-aged children with autism spectrum disorder (ASD).Method: Twelve school-age children with ASD who use an SGD as their primary mode of communication participated in the study. The percentage of time the child was within the proximity of their device was calculated over nine videotaped sessions and data logging provided information regarding device use over an 18-week period.Result: Children were in proximity to their device 65% of the time. There was a significant positive correlation between percentage of time in proximity to device and the average minutes of device use on the day video recorded. Exploratory analyses revealed that communicative abilities may be more connected to proximity than school context.Conclusion: These results support the importance of developing a program for assuring device proximity in order to encourage consistent device use in minimally verbal ambulatory school-age children with ASD.

Mapping epilepsy-specific patient-reported outcome measures for children to a proposed core outcome set for childhood epilepsy.

OBJECTIVE: The objectives of the study were to (1) map questions in epilepsy-specific patient-reported outcome measures (PROMs) of children's health-related quality of life (HRQoL) to a proposed core outcome set (COS) for childhood epilepsy research and (2) gain insight into the acceptability of two leading candidate PROMs. METHOD: We identified 11 epilepsy-specific PROMs of children's HRQoL (17 questionnaire versions) in a previous systematic review. Each item from the PROMs was mapped to 38 discrete outcomes across 10 domains of the COS: seizures, sleep, social functioning, mental health, cognition, physical functioning, behavior, adverse events, family life, and global quality of life. We consulted with three children with epilepsy and six parents of children with epilepsy in Patient Public Involvement and Engagement (PPIE) work to gain an understanding of the acceptability of the two leading PROMs from our review of measurement properties: Quality of Life in Childhood Epilepsy (QOLCE-55) and Health-Related Quality of Life Measure for Children with Epilepsy (CHEQOL). RESULTS: Social Functioning is covered by all PROMs except DISABKIDS and G-QOLCE and Mental Health is covered by all PROMs except G-QOLCE and Hague Restrictions in Childhood Epilepsy Scale (HARCES). Only two PROMs (Epilepsy and Learning Disability Quality of Life (ELDQOL) and Glasgow Epilepsy Outcome Scale (GEOS-YP)) have items that cover the Seizure domain. The QOLCE-55 includes items that cover the domains of Physical Functioning, Social Functioning, Behavior, Mental Health, and Cognition. The CHEQOL parent and child versions cover the same domains as QOLCE-55 except for Physical Functioning and Behavior, and the child version has one item that covers the discrete outcome of Overall Quality of Life and one item that covers the discrete outcome of Relationship with parents and siblings. The QOLCE-55 parent version was acceptable to the parents we consulted with, and CHEQOL parent and child versions were described as acceptable to our child and parent advisory panel members. SIGNIFICANCE: Mapping items from existing epilepsy-specific PROMs for children is an important step in operationalizing our COS for childhood epilepsy research, alongside evaluation of their measurement properties. Two leading PROMS, QOLCE-55 and CHEQOL, cover a wide range of domains from our COS and would likely be used in conjunction with assessment tools selected for specific study objectives. The PPIE work provided practical insights into the administration and acceptability of candidate PROMs in appropriate context. We promote our COS as a framework for selecting outcomes and PROMs for future childhood epilepsy evaluative research.

The Relationship Between Operational Competency, Buy-In, and Augmentative and Alternative Communication Use in School-Age Children With Autism.

Purpose The objective of this study was to investigate the relationship between 2 variables that influence augmentative and alternative communication (AAC) use, caregiver operational competency (i.e., the ability to navigate, customize, and program the device), and AAC system buy-in (i.e., understanding that the device acts as the child's voice and should be treated as an extension of his or her physical body), to determine if there was a relationship between these variables and device use at home and at school in school-age children with autism who use AAC. Method The device use of 29 school-age children ( M age = 7.82 years) with an educational diagnosis of autism who use AAC was tracked using the logging feature on the participants' AAC devices. Participants' parents ( n = 29) and teachers ( n = 14, some teachers reported on multiple students) completed a questionnaire assessing caregiver operational competency and AAC system buy-in. Minutes of data use were extracted from each participant's AAC device ( Cross & Segalman, 2016 ) and averaged across three randomly selected dates. Results The parents and teachers reported high rates of operational competency and buy-in. However, only 10 of the children used their devices at home during the weekends. Despite high rates of parent- and teacher-reported operational competency, participants did not use their devices at high rates. Conclusion Speech-language pathologists may also need to focus on other aspects of parent and teacher training, such as creating communication opportunities for students who use AAC to increase device use at home and at school.

Framework for Selecting Vocabulary for Preliterate Children Who Use Augmentative and Alternative Communication.

Purpose Nearly 50% of school-based speech-language pathologists (SLPs) provide services to school-age children who use augmentative and alternative communication (AAC). However, many SLPs report having insufficient knowledge in the area of AAC implementation. The objective of this tutorial is to provide clinicians with a framework for supporting 1 area of AAC implementation: vocabulary selection for preliterate children who use AAC. Method This tutorial focuses on 4 variables that clinicians should consider when selecting vocabulary: (a) contexts/environments where the vocabulary can be used, (b) time span during which the vocabulary will be relevant, (c) whether the vocabulary can elicit and maintain interactions with other people, and (d) whether the vocabulary will facilitate developmentally appropriate grammatical structures. This tutorial focuses on the role that these variables play in language development in verbal children with typical development, verbal children with language impairment, and nonverbal children who use AAC. Results Use of the 4 variables highlighted above may help practicing SLPs select vocabulary that will best facilitate language acquisition in preliterate children who use AAC.

Core Health Outcomes in Childhood Epilepsy (CHOICE): Development of a core outcome set using systematic review methods and a Delphi survey consensus.

OBJECTIVE: Establishing a core set of outcomes to be evaluated and reported in intervention trials aims to improve the usefulness of health research. There is no established core outcome set (COS) for childhood epilepsies. The aim of this study was to select a COS to be used in evaluative research of interventions for children with rolandic epilepsy (RE). METHODS: We followed guidance from the COMET (Core Outcome Measures in Effectiveness Trials) Initiative. First, we identified outcomes that had been measured in research through a systematic review. Second, young people with RE, parents, and professionals were invited to take part in a Delphi survey in which participants rated the importance of candidate outcomes. Last, a face-to-face meeting was convened to seek consensus on which outcomes were critical to include and to ratify the final COS. RESULTS: From 37 eligible papers in the review, we identified and included 48 candidate outcomes in the survey. We sent invitations to 165 people registered to take part in the survey; of these, 102 (62%) completed Round 1, and 80 (78%) completed Round 2 (three young people, 16 parents, 61 professionals). In Round 2 we included four additional outcomes suggested by participants in Round 1. The consensus meeting included two young people, four parents, and nine professionals who were eligible to vote and ratified the COS as 39 outcomes across 10 domains. SIGNIFICANCE: Our methodology was a proportionate and pragmatic approach toward producing a COS for evaluating research on interventions aiming to improve the health of children with RE.

Aerobic and strength training exercise programme for cognitive impairment in people with mild to moderate dementia: the DAPA RCT.

BACKGROUND: Approximately 670,000 people in the UK have dementia. Previous literature suggests that physical exercise could slow dementia symptom progression. OBJECTIVES: To estimate the clinical effectiveness and cost-effectiveness of a bespoke exercise programme, in addition to usual care, on the cognitive impairment (primary outcome), function and health-related quality of life (HRQoL) of people with mild to moderate dementia (MMD) and carer burden and HRQoL. DESIGN: Intervention development, systematic review, multicentred, randomised controlled trial (RCT) with a parallel economic evaluation and qualitative study. SETTING: 15 English regions. PARTICIPANTS: People with MMD living in the community. INTERVENTION: A 4-month moderate- to high-intensity, structured exercise programme designed specifically for people with MMD, with support to continue unsupervised physical activity thereafter. Exercises were individually prescribed and progressed, and participants were supervised in groups. The comparator was usual practice. MAIN OUTCOME MEASURES: The primary outcome was the Alzheimer's Disease Assessment Scale - Cognitive Subscale (ADAS-Cog). The secondary outcomes were function [as measured using the Bristol Activities of Daily Living Scale (BADLS)], generic HRQoL [as measured using the EuroQol-5 Dimensions, three-level version (EQ-5D-3L)], dementia-related QoL [as measured using the Quality of Life in Alzheimer's Disease (QoL-AD) scale], behavioural symptoms [as measured using the Neuropsychiatric Inventory (NPI)], falls and fractures, physical fitness (as measured using the 6-minute walk test) and muscle strength. Carer outcomes were HRQoL (Quality of Life in Alzheimer's Disease) (as measured using the EQ-5D-3L) and carer burden (as measured using the Zarit Burden Interview). The economic evaluation was expressed in terms of incremental cost per quality-adjusted life-year (QALY) gained from a NHS and Personal Social Services perspective. We measured health and social care use with the Client Services Receipt Inventory. Participants were followed up for 12 months. RESULTS: Between February 2013 and June 2015, 494 participants were randomised with an intentional unequal allocation ratio: 165 to usual care and 329 to the intervention. The mean age of participants was 77 years [standard deviation (SD) 7.9 years], 39% (193/494) were female and the mean baseline ADAS-Cog score was 21.5 (SD 9.0). Participants in the intervention arm achieved high compliance rates, with 65% (214/329) attending between 75% and 100% of sessions. Outcome data were obtained for 85% (418/494) of participants at 12 months, at which point a small, statistically significant negative treatment effect was found in the primary outcome, ADAS-Cog (patient reported), with a mean difference of -1.4 [95% confidence interval (CI) -2.62 to -0.17]. There were no treatment effects for any of the other secondary outcome measures for participants or carers: for the BADLS there was a mean difference of -0.6 (95% CI -2.05 to 0.78), for the EQ-5D-3L a mean difference of -0.002 (95% CI -0.04 to 0.04), for the QoL-AD scale a mean difference of 0.7 (95% CI -0.21 to 1.65) and for the NPI a mean difference of -2.1 (95% CI -4.83 to 0.65). Four serious adverse events were reported. The exercise intervention was dominated in health economic terms. LIMITATIONS: In the absence of definitive guidance and rationale, we used a mixed exercise programme. Neither intervention providers nor participants could be masked to treatment allocation. CONCLUSIONS: This is a large well-conducted RCT, with good compliance to exercise and research procedures. A structured exercise programme did not produce any clinically meaningful benefit in function or HRQoL in people with dementia or on carer burden. FUTURE WORK: Future work should concentrate on approaches other than exercise to influence cognitive impairment in dementia. TRIAL REGISTRATION: Current Controlled Trials ISRCTN32612072. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full programme and will be published in full in Health Technology Assessment Vol. 22, No. 28. See the NIHR Journals Library website for further project information. Additional funding was provided by the Oxford NIHR Biomedical Research Centre and the Oxford NIHR Collaboration for Leadership in Applied Health Research and Care.

A qualitative study of older people's experience of living with neurogenic claudication to inform the development of a physiotherapy intervention.

PURPOSE: The aim of this study was to explore older people's experiences of living with neurogenic claudication (NC), their preferences for physiotherapy treatment provision and associated outcomes in order to inform an intervention to be tested in a clinical trial. METHOD: Patients with a diagnosis of NC and/or lumbar spinal stenosis were recruited through a UK NHS tertiary care center. Semi-structured interviews and self-report questionnaires were used to obtain data. A thematic analysis was conducted. RESULTS: 15 participants were recruited; half were classed as frail older adults. Pain and the threat of pain was a prominent feature of participants' experience of NC. This led to a loss of engagement in meaningful activities and sense of self. Discourses of ageing influenced experiences as well as treatment preferences, particularly the acceptability of walking aids. A combination of one-to-one and group setting for treatment was preferred. Outcome preferences related to re-engagement in meaningful activities and pain reduction. Limitations relate to generalisability of the findings for NC patients not under physiotherapy treatment. CONCLUSION: We have obtained important findings about older people's experiences of living with NC and preferences for physiotherapy treatment and outcomes. These will be incorporated into an evidence-based intervention and evaluated in a randomized controlled trial. Implications for rehabilitation Older people living with NC want to get back to meaningful activities and learn how to live with the threat of pain. Allied health professionals (AHPs) should be sensitive to the complex and ambiguous ways in which older people live with ageing and age-related decline. AHPs are in a position to support patients' successful transition to the use of walking aids thereby reducing stigmatizing effects and increasing activity. AHPs should consider a mixture of one-to-one and group classes to enable rehabilitation for older NC patients.

Dementia and Physical Activity (DAPA) - an exercise intervention to improve cognition in people with mild to moderate dementia: study protocol for a randomized controlled trial.

BACKGROUND: Dementia is more common in older than in younger people, and as a result of the ageing of the population in developed countries, it is becoming more prevalent. Drug treatments for dementia are limited, and the main support offered to people with dementia and their families is generally services to mitigate against loss of function. Physical exercise is a candidate non-pharmacological treatment for dementia. METHODS/DESIGN: DAPA is a randomised controlled trial funded by the National Institute for Health Research Health Technology Assessment programme to estimate the effect of a 4-month, moderate- to hard-intensity exercise training programme and subsequent advice to remain active, on cognition (primary outcome) at 12 months in people with mild to moderate dementia. Community-dwelling participants (with their carers where possible), who are able to walk 3 metres without human assistance, able to undertake an exercise programme and do not have any unstable or terminal illness are recruited. Participants are then randomised by an independent statistician using a computerised random number generator to usual care or exercise at a 2:1 ratio in favour of exercise. The exercise intervention comprises 29, 1-hour-long exercise classes, run twice weekly at suitable venues such as leisure centres, which include aerobic exercise (on static bikes) and resistance exercise (using weights). Goals for independent exercise are set while the classes are still running, and supported thereafter with phone calls. The primary outcome is measured using ADAS-cog. Secondary outcome measures include behavioural symptoms, functional ability, quality of life and carer burden. Primary and secondary outcomes will be measured at baseline and at 6 and 12 months after randomisation, by researchers masked to participant randomisation in the participants' own homes. An economic evaluation will be carried out in parallel to the RCT, as will a qualitative study capturing the experiences of participants, carers and staff delivering the intervention. DISCUSSION: The DAPA study will be the first large, randomised trial of the cognitive effects of exercise on people with dementia. The intervention is designed to be capable of being delivered within the constraints of NHS service provision, and the economic evaluation will allow assessment of its cost-effectiveness. TRIAL REGISTRATION: DAPA was registered with the ISRCTN database on 29 July 2011, registration number ISRCTN32612072 .

Variation in stop consonant voicing in two regional varieties of American English.

This study is an acoustic investigation of the nature and extent of consonant voicing of the stop /b/ in two dialectal varieties of American English spoken in south-central Wisconsin and western North Carolina. The stop /b/ occurred at the juncture of two words such as small bids, in a position between two voiced sonorants, i.e. the liquid /l/ and a vowel. Twenty women participated, ten representing the Wisconsin and ten the North Carolina variety, respectively. Significant dialectal differences were found in the voicing patterns. The Wisconsin stop closures were usually not fully voiced and terminated in a complete silence followed by a closure release whereas North Carolina speakers produced mostly fully voiced closures. Further dialectal differences included the proportion of closure voicing as a function of word emphasis. For Wisconsin speakers, the proportion of closure voicing was smallest when the word was emphasized and it was greatest in non-emphatic positions. For North Carolina speakers, the degree of word emphasis did not have an effect on the proportion of closure voicing. The results suggest different mechanisms by which closure voicing is maintained in these two dialects, pointing to active articulatory maneuvers in North Carolina speakers and passive in Wisconsin speakers.