MENTAL HANDICAP VOL. 19 DECEMBER 1991

A Communication Course for Adults with Profound Intellectual Disability and Physical Disabilities

Keith Park

From September to December 1989 Ipswich TAFE (an adult education facility near Bris- bane, Queensland) hosted a Communication Course for five adults who each have a profound intellectual disability and physical disability (in the UK this is the equivalent of profound and multiple learning difficulties). None of the five students possess skills of intentional communication. The course is believed to be the first one of its kind in Australia and was of an experimental nature. The course content is described. The main aim of this presentation is to share information and to invite collabor- ation from others in similar areas of work.

Introduction When the opportunity arose to run a course for

adults with profound intellectual disability and physical disability, it was under circumstances that had been decided by the various local administrative authorities. Therefore, there were various factors influencing the course. Firstly, the author, who had been asked to run the course, had met only two of the students. Secondly the allocated resources amounted to one room in a local TAFE college and the course was to be one hour per week. Thirdly, each student would have an attendant. Since three of the students were from a large residential placement for people with severe disabilities, and two of the students were living with their families and attending a community access support service for people with severe disabilities, this meant that each student would be attended by a member of care staff. These factors placed important con- straints upon the course design and content.

The immediate practical concern was: are there realistic and age-appropriate strategies to encourage intentional communication skills in the person who does not communicate intentionally? A second consideration was whether there is an appropriate

theoretical model of communication development upon which to base the course content.

The main part of this paper describes the explo- ration of the first issue, and the course outline is presented below. The theoretical issues are reviewed briefly first. Although the theories of Bates (1976) and also those of Lisina (1983) have proved useful, it is obviously too early to comment on the relationship between theory and practice, and in particular how far the theories of Bates and her colleagues can provide a useful guide for work with adults with severe disabilities.

The work of Bates (1976) describes a sequence of communicative development that may be of particular relevance for people with a profound intellectual disability. Mustonen et al. (1991) provide a brief outline of Bates’ proposed three stages of communicative behaviour observed in infants. The first perlocutionary stage is one in which ‘although the infant is not aware of the communicative value of his or her acts, the caregivers respond to the behaviours as though the infant were attempting to communicate through them’ (p. 24). Examples include an infant crying and the caregiver inferring thirst or hunger, discomfort, etc. An infant smiling may be interpreted by the caregiver to mean that the infant is expressing contentment. The suggestion is that the behaviour has not been intentionally produced for a listener, although the listener may respond as though there was intention in the behaviour.

As infants mature, these types of behaviour may become intentional communications to a prospective listener. These types of intentional goal-directed behaviours are described as comprising the illocu- tionary stage and are characterised by the ‘growing use of behaviours produced with the intent of controlling others’ (p. 24). These behaviours may include the use of objects in various ways, repetition of behaviours that resulted in reward, and pointing. Mustonen et al. then report that eventually ‘the locutionary phase signals the emergence of words

KEITH PARK is a teacher in special education, based in Queensland, Australia.

0 1991 BlMH Publications 165

MENTAL HANDICAP VOL. 19 DECEMBER 1991

that are used as symbols’ (p. 25, emphasis added). McClean & Snyder-McClean (1988) have proposed

that these three stages are of relevance for people who have severe andlor multiple disabilities. How- ever, although these concepts have been applied to the education of children with severe learning difficulties (Coupe & Goldbart, 1988), it appears that little attention has been given to adults who do not communicate intentionally.

An example of ‘perlocutionary effect’ was pro- vided by observations of K. with her caregivers. K. was 19 years old, and did not have any formal expressive means of communicating. Her family and caregivers reported that occasionally she would burst into tears, but for no apparent reason. Her family and caregivers would interpret this behaviour to mean, according to their understanding of the context in which it occurred, hunger, thirst, bore- dom, a desire to change the activity or change the environment, or over-excitement. Similarly, K. would sometimes laugh - at which time her caregivers would interpret happiness, a wish for repetition, a feeling of comfort, excitation, etc. Nevertheless, family and caregivers felt certain that K.’s behaviours were not intentional messages.

Description and aims of the course The course took place at Ipswich TAFE and lasted

for 20 one-hour sessions over 18 weeks. There were five female students aged between 17 and 30, each of whom came with an attendant, and a teacher who led the session. Advice concerning some of the students was available from a physiotherapist, occupational therapist, and speech therapist.

Since the course tutor had met only two of the students before the beginning of the course, the initial group aims of the course were general and exploratory by nature. They were as follows:

(1) To develop four aspects of early communi-

(a) to encourage and develop any attention and interest the student may show in another person.

(b) to encourage the student to give a response to another person.

(c) to encourage and develop any behaviour of the student by which she will try to attract the attention of another person.

(d) to encourage the student to evoke from another person a response to what she is doing.

cation skills; (see Lisina, 1983)

(2) To present opportunities for the student to

(3) To explore the auditory and visual skills of

make choices.

each student.

It was anticipated that from these group aims, individual needs would become apparent.

Rationale: Using the principles of Augmentative Communication

The Makaton Vocabulary is ‘.. . an open ended lexicon, based around a common core of functional concepts, which is taught with manual signs and/or graphic symbols, accompanied by speech’ (Grove & Walker, 1990: 15). The authors propose ‘that individuals should have the opportunities of using all channels of communication that may be appropri- ate to their needs’ (p. 19). The rationale for this course was based upon an interpretation of this statement: that people who did not communicate intentionally, should have access to all channels of communication. Nevertheless, this access should be planned and structured. A limited use of symbols might take place alongside the use of speech, sign, mime, and gesture, even though symbol use was not initially intended for referential purposes, but as interesting objects that might hold visual attention. Makaton symbols were used as the basis for symbol design for the following reasons:

The design features of Makaton symbols (Walker, 1985) meant that the symbols could be easily personalised, modified according to subsequent information concerning visual acuity, and enlarged or reduced in size by being re-drawn. There was one symbol card for each student attending the course and the symbols were individualised in various ways to encourage interest - each person’s card had the initial letter of their name on it, each was a different colour, some were fluorescent, and some were scented.

Use of a symbol system that was flexible and open-ended meant that if any student developed some kind of symbolic represen- tation then the same materials could be used to enhance those skills, and yet still be used for their original purpose with others.

Two of the students had also been exposed to some signs from the Makaton Vocabulary from caregivers including the concepts: ‘me’, ‘you’, ‘look’, ‘hello’, ‘goodbye’, ‘here’, ‘there’. However, this information was anecdotal and there was no written information concerning previous communication work. Using Maka- ton Symbols alongside signs from the Makaton Vocabulary - signs that might have been seen by some or all of the students - was a way of providing some kind of continuity from previous communication programmes.

The use of visual, auditory, and tactile ‘signs’ to indicate the beginning and ending of certain activi-

166 0 1991 BlMH Publications

MENTAL HANDICAP VOL. 19 DECEMBER 1991

ties has been described elsewhere (Park, Robinson & Williams, 1989) and is not discussed here for reasons of space.

Communication Course: Component 1. Introduction (5-10 minutes)

Aims

To provide an environmental signal indicating that the group session is beginning. To establish a relaxed and informal atmosphere. To encourage choice-making by means of eye- pointing.

Equipment

Tape recorder, tape, wrist-bands, scent bottles.

Procedure

(a) When the group is assembled, the tape recorder is switched on and t,he ‘Introduction’ music is played (‘Red Red Wine’, UB40). (b) The group leader then presents to each student two bottles of scented oil to smell. The student is encouraged to look at the preferred choice, which is then dabbed on to a wristband that will be worn by student’s attendant for that session. When there is no visible reaction from the student, an arbitrary choice is made on their behalf. This process is repeated until each attendant is wearing a scented wrist-band.

Communication Course: Component 2. Joint reference (15-20 minutes)

Aims

To develop visual tracking skills. To establish skills of joint reference.

Equipment

Symbol cards (A4 size), torch (the procedure takes place with all room lighting switched off).

Procedure

(a) The group leader holds up a symbol card belonging to one of the students, places it on the display (screen or blackboard), and then shines the torch on it. (b) The group leader then shines the torch on the student, repeating the student’s name. This procedure is then repeated with the students’ attendant. (c) This procedure is repeated for each student- attendant pair. Students are encouraged to look at each symbol card and to look at the person to whom it belongs.

Communication Course: Component 3. Hand Massage (15 minutes)

Aims

To increase the student’s toleration of another person. To encourage eye contact and interaction between the student and the attendant.

Equipment

OiVcream for massage, tape recorder and tape (‘Medieval and Renaissance Music for Harp and Vielle’).

Procedure

Each attendant will follow the procedure set out below with student, firstly with the right hand and then the left. All movements should be performed

(a) Beginning: say hello and tell the student your name. Place the palm of the student’s hand on your scented identity band while this is being done. (b) Stroke the student’s whole hand from wrist to finger tips (5 times). Massage fingers: thumb, fifth finger, second, fourth, and then third finger (3 times). Massage palm and back of hand to finger tips ( 3 times). (c) Ending: press back of hand gently back and then hold; interlock fingers and gently shake (once). (d) Repeat the process with the other hand.

slowly.

Communication Course: Component 4. Taste Section (15-20 minutes)

Aims

To discover individual preferences in food taste, texture, and temperature. To improve skills of assisted eating.

Equipment

Food items, cutlery as required.

Procedure

(a) The group leader presents the food item(s) to be tried, and briefly takes it or them around the whole group to be smelled andor touched. Each student then tries the food item, assisted by their attendant. (b) Each student’s responses (i.e. likes, dislikes etc.) are recorded by their attendant in the course file.

- ~~~ ~~

0 1991 BlMH Publications 167

MENTAL HANDICAP VOL. 19 DECEMBER 1991

Communication Course: Component 5. Conclusion (10 minutes)

Aims

To provide an environmental signal indicating that the group session is ending.

Equipment

Tape and tape recorder, sparklers, matches.

Procedure (a) The first part follows the procedure of compon- ent two but in reverse: the symbol cards are thus put away. (b) Then, positioned as in the introductory session, the group listens to a five minute piece of music (Canon in G, by J. Pachelbel), while sparklers are burned in front of everyone.

Discussion and conclusion It is not possible to present an evaluation of the

course. The main reason for this - agreed by all the staff - was that it took the 20-weeks duration of the course for the students to become familiar with the setting and the people.

Components 1 and 5(b) (Introduction and Conclusion) were felt to be an appropriate method of beginning and ending the group session. After eight weeks of the joint reference activities (Components 2 and 5(a)) using symbols, three students were tracking the symbol cards as they were taken out and replaced. Furthermore, two students were observed to look from the symbol card to the appropriate individual on four (non- consecutive) occasions.

This was problematic, mainly becasue it was entirely unforeseen, and secondly because, as Doss & Reichle (1989) suggest: ‘pragmatic intent is not observable’ (p. 103). Given the context within which the behaviours were observed, it cannot be proved that the behaviours were ‘illocutionary’.

However, in order to incorporate the possibility that the behaviour’s indicated intent, and to continue encouraging tracking skills and joint reference, the symbol cards were modified as follows: each (A4 size) symbol card had its own smaller version (measuring 2 crns by 3 crns) placed on the large card, over the ‘name’ section (i.e. the initial letter). The procedure for component 2 was then as follows:

(a) The group leader holds up a symbol card belonging to one of the students, places it on the display (screen or blackboard), and then shines the torch on it.

(b) Still shining the torch on the large symbol card, the small symbol card is detached from

it, slowly taken - under torchlight - to the student and fastened to their shirt/lapel/etc.

(c) The group leader then stands by the large symbol and shines the torch on it, saying who it is, and then shines the torch to the small symbol card now attached to the student, repeating the student’s name. This procedure is then repeated with the student’s attendant.

(d) This procedure is repeated for each student- attendant pair.

The section 5(a) then became the reverse of this procedure, and the small symbol cards were taken from each person and re-attached to their larger versions on the display board.

The results of this were inconclusive. If pragmatic intent is not observable, the interpretation of the behaviours involves non-quantifiable possibilities. The observations permit at least three interpret- ations:

(1) the behaviours are non-intentional and ran- dom, although they have perlocutionary effects upon caregivers, who respond as if there is intent.

(2) the behaviours are illocutionary (i.e. intentional) but are not necessarily being correctly ‘interpreted’ by caregivers. The stud- ents attempts at communication may be misunderstood and/or misinterpreted.

(3) the behaviours may vary from non-intentional to intentional each time they were observed.

Component 3, the hand message, was felt by all staff to be a successful activity in helping to develop a bond between the student and attendant, and was an appropriate activity from which to work on group aim one. In component 4, the ‘taste’ section, each student had the opportunity to taste a different food item each week. Advice was given from a speech therapist concerning the eating skills of each student. Food items included fresh fruit (e.g. paw paw, pineapple, passion fruit), fresh vegetables (e.g. radish, shallott, celery), types of meat (liver sausage, black pudding, pate), types of seafood (e.g. rollmop, crab meat, shrimp paste) as well as assorted items (e.g. salted guava, cuttlefish, tamarind candy) found in local shops. Some unusual preferences were discovered!

There was no time to develop an evaluation procedure. This was because it took all of the 20 weeks to get to know the students and secondly, because it probably took all of the 20 weeks for the students to familiarise themselves with the setting. The development of an evaluation procedure is planned for the next term’s course. Thus, there are no claims made for the effectiveness of the

168 0 1991 BlMH Publications

MENTAL HANDICAP VOL. 19 DECEMBER 1991

procedure. The main purpose of this paper is to share information with others who are working under similar conditions elsewhere. It is to continue in 1990 with the same student group, and so we would welcome comments and, in particular, information from anyone doing similar work.

REFERENCES Bates, E. (1976) Language and Context: The Acqui-

sition of Pragmatics. New York: Academic Press. Coupe, J. and Goldbart, J. (eds) (1988) Communi-

cation Before Speech. London and Sydney: Croom Helm.

Doss, S. and Reichle, J. (1989) Establishing com- municative alternatives to the emission of socially motivated excess behaviour. Journal of the Association f o r Persons with Severe Handicaps 14 (a), 101-12.

Grove, N. and Walker, W. (1990) The Makaton vocabulary. Using manual signs and graphic symbols to develop interpersonal communication. Augmentative and Alternative Communication 6 (l), 15-28.

Lisina, M. (1983) Child - Adults - Peers. Moscow: Progress Publishers.

McClean, J. E. and Snyder McClean, L. (1988) Application of pragmatics to severely mentally- retarded children and youth. In R. L. Schiefelbusch and L. L. Lloyd (eds) Language Perspectives: Acquisition, Retardation, and Intervention. Aus- tin (Texas): Pro-ed.

Mustonen, T., Locke, P., Reichle, J., Solbrack, M. and Lindgren, A. (1991) An overview of augmentative and alternative communication sys- tems. In J. Reichle, J. York and J. Sigafoos (eds) Implementing Augmentative and Alternative Communication. Baltimore: Paul Brookes.

Park, K., Robinson, B. and Williams C. (1989) Communication as Curriculum: A Framework fo r Working with Children with Dual Smsory Impairment and Profound and Multiple Learn- ing Dif3culties. London: Teachers’ Centre for Special Education, SE1 8QW.

Walker, M. (ed.) (1985) Symbols f o r Makaton. Camberley (UK): MVDP/EARO Press.

Address for correspondence: Keith Park, 39 Bayford Street, Oxley, Queensland 4075, Australia.

Parents on Dyslexia Edited by Saskia VAN DER STOEL A practical book for all involved with dyslexia: not only parents and teachers, but also the staff of schools advisory services, family doctors, etc. 1990 192 pages

Orders and sales enquiries to: Multilingual Matters, Bank House, 8a Hill Road, Clevedon, Avon BS217HH

Hbk 1-85359-077-0 E28.00 Pbk 1-85359-076-2 $3.95

Tel. (0275) 876519

I CURRENT

and training I

INFORMATION & RESOURCE CENTRE

provides up-to-date information on current resources

INFORMATION SERVICE /

LIBRARY SERVICE

BIMH -

WE CAN HELP YOU MEET YOUR STAFF TRAINING NEEDS

BIMH Education and Training provides a nationwide programme of training events.

Conferences cover all aspects of research and innovative practice in the field of learning difficulties.

Our Courses and Workshops provide participants with knowledge, practical skills and positive attitudes.

BIMH In-house Training provides flexible training for your staff in your workplace by:

Helping you to identify your training

0 Structuring training packages for your

0 Providing experienced workshop tutors

needs

organisation

For further details of the above services, please contact either:

Linda Averill, Information and Resources Officer or Jenny May, Training Officer at: BIMH, Wolverhampton Road, Kidderminster, Worcs. DYlO 3PP Tel. 0562-850251

0 1991 BIMH Publications 169