Fresh Look: AAC for Children Who Have Rett Syndrome with Dr. Theresa Bartolotta

In our SLP training programs, few of us learned about Rett Syndrome or how to provide services to children with that disorder. We’re so pleased to have a guest post on AAC services for children with Rett by Dr. Theresa Bartolotta, Director of Assessment in the Office of the Provost, and Associate Professor in the Department of Speech-Language Pathology, at Seton Hall University, in South Orange, New Jersey. An SLP with over 30 years of clinical experience, she specializes in communication disorders in children with significant disabilities with a special interest in autism and Rett syndrome. Our field is still learning about Rett syndrome and we are still discovering new things about the range of skills and abilities present in the children who have it. In this post, Dr. Bartolotta gives us some background about the syndrome and discusses implications for treatment.

I am thrilled to have this opportunity to post about Rett syndrome, and share some strategies on successful use of AAC with individuals with Rett on this blog!!  Thanks to Carole Zangari for this gracious invitation.

Background

I began working with individuals with Rett syndrome (RTT) about 15 years ago, and at that time, there was very little information available for clinicians, teachers and families regarding best practices in working with this population. Rett Syndrome was initially described in the 1960’s in Europe, and the first individual with RTT was diagnosed in the U.S. in the 1980’s. A fairly rare disease, it occurs in approximately 1:10,000 live female births, but is the second-most common cause of severe intellectual disability in females. RTT does occur in males, though less frequently than females, and most times the males are very severely affected.

So – why is there so much interest in RTT and why are more and more clinicians seeing cases of RTT?

Genetic Cause

The genetic mutation that causes RTT was identified in 1999 and as a result, a great deal of interest in the disorder has been generated since that time.  RTT most commonly occurs as a spontaneous mutation on the X chromosome in the MECP2 gene. This gene plays a major role in the development of the brain and in healthy brain function throughout the lifespan.  At present there are countless studies underway to learn more about this very complex gene, and more importantly, to identify clinical treatments, and eventually, a cure.   The diagnosis of RTT is made clinically, typically by a developmental pediatrician or neurologist, and then confirmed through a blood test. Many early cases of RTT are initially misdiagnosed as autism, especially when the signs of the disorder first become apparent.  Until recently RTT was considered to be part of the autism spectrum, but with the release of the new DSM 5 this year, it is no longer listed as an autism spectrum disorder.

The finding of the gene has resulted in more accurate diagnosis of RTT and better understanding of the challenges faced by individuals and their families. As recently as 10 years ago, individuals with RTT were believed to be incapable of intentional communication and likely faced the loss of all motor skills at an early age, and an early death. We now know this is not the case. It is not a degenerative disorder. Many individuals with RTT live well into middle age, retain walking skills and some hand function and participate in their community.  We are beginning to learn about the variations in cognitive and communication ability as well. Though most individuals are severely cognitively challenged, nonverbal, and dependent for self-care, they tend to be very social and interested in people and various activities. The key challenge is how to identify the best way for the individual to communicate and to maximize their potential.

Characteristics of RTT

Individuals with RTT have severe challenges in cognition, communication and motor function.  Here are some key facts:

• Symptoms usually appear between six-18 months of age
• Most infants with RTT appear to function normally until experiencing a regression in motor skills, language and cognition sometime before the second birthday
• The period of regression can last for several years
• Most individuals can then regain skills, or learn some new skills, in later childhood through adulthood
• Seizures, respiratory, and feeding problems are often present
• Hand function is usually very limited
• Apraxia is commonly observed and affects most body movements
• The overwhelming majority will be nonverbal and not develop functional spoken language skills
• Many individuals with RTT have excellent eye gaze – this modality has strong potential for communication
• Early intervention with AAC can assist in development of communication and cognitive skills and improve quality of life for those with Rett syndrome

Assessment of Communication

Because of the complexity of the disorder, standardized tests usually do not provide the most functional, clinically applicable or relevant information for clinicians to identify the best approach to designing communication intervention. Two tools which I recommend are The Inventory of Potential Communicative Acts (IPCA) (Sigafoos et al.,2006)  and The Communication Matrix (see references at the end).  Each of these tools use a series of questions to gather information from a communication partner of the individual you are assessing.  These are highly functional ways to gather useful information about communication and social behaviors of individuals who are at a prelinguistic or early linguistic level of communication development.

Communication Intervention

Most individuals with RTT will not develop functional verbal skills. So, for this population, implementation of AAC strategies EARLY will help provide the best outcomes.  Volitional hand control is usually limited because of severe difficulties with apraxia. They often need additional time to generate a response, so keep that in mind when asking questions or giving a command.

Many individuals with RTT use nonstandard behaviors for communication. For example, to make a request, a person with RTT may walk towards or lean towards an object. Some of the behaviors to be on the lookout for are: vocalizations, laughing, crying, eye gaze, head or body movements.  These nonstandard behaviors are often described as prelinguistic, in that they don’t fit the criteria for symbolic communication, but if acknowledged as communicative or potentially communicative, a meaningful, symbolic act can be shaped. The communication partner, someone who is familiar with the individual with RTT, can provide an abundance of information about interests and help you interpret the meaning of these behaviors.

Consideration of alternative access for AAC using body parts other than the hands, including head, arm, or eyes should be a primary goal.  Persons with RTT are often described as making consistent eye contact with others, so this is a good modality to begin to explore. There’s lots of interest at present in using electronic eye gaze systems, and there’s some excellent research that demonstrates individuals with RTT have gaze patterns similar to typically developing children (Djukic & McDermott, 2012; Djukic et al, 2012).  However, before making significant investments of time, money and other resources in electronic systems, you may want to consider trying to utilize low-tech or no-tech eye gaze options, using partner-assisted scanning.

Here are some ideas for Best Practices in AAC Intervention for RTT:

• Begin by teaching a simple requesting response
• Ensure the targeted response is within the individual’s physical abilities – consider nonstandard behaviors
• Consider a simple motor act rather than speech or gestures
  • Touch a switch
  • Hand movement
  • Natural gesture
  • Assess use of eye gaze
    • Offer choices
    • Develop consistency across two favored objects
    • Explore expanding set to three or more choices
    • Begin with no-tech; establish a consistent, valid level of response
    • However, allow for inconsistency (remember – apraxia can affect consistent motor responses)
    • Allow time to respond – many individuals with RTT have delayed responses – asses an individual and adjust your expectations
    • Move to low-tech or high-tech, depending upon:
      • Interest level
      • Skill
      • Resources
      • Contexts

Specific Interventions

The evidence for successful use of AAC with RTT is limited, but here are some techniques that are discussed widely in the RTT community:

• Communication Coaching –See Bartolotta & Remshifski (2013) for more information.
  • The communication partner is the best resource to interpret what behaviors mean
  • Coaching is highly effective in terms of SLP time and resources
  • You can implement any type of AAC strategy into a coaching model
  • How to do it:
    • Observe an interaction between an individual with RTT and a familiar person
    • Provide targeted strategies to implement during familiar settings, such as:
      • Offer choices
      • Increase wait time to allow for responses
      • Acknowledge behaviors that can be potentially communicative
        • Eye gaze, open mouth, vocalization, hand and body movements
        • Ask questions or make comments that require responses

• PODD
  • Pragmatic Organization Dynamic Display Communication Books – developed by Gayle Porter
  • Provides guidelines and templates for communication books

• Contains tips for teaching strategies and how to choose relevant, motivating vocabulary

• Books can be accessed using direct selection, scanning, partner-assested scanning

• Available from Mayer-Johnson (www.mayer-johnson.com)

• See Linda Burkhart’s website for information on training opportunities for PODD
  

• Electronic eyegaze systems
  • Infrared cameras provide access to a range of devices using eyegaze
  • Very population devices: Dynavox Eyemax, TobiiC12 or C15 Communicators
  • Emerging  interest in using this type of AAC strategy given the strong eye gaze modality we observe in those with RTT
  • Suggestions for implementation
    • First establish consistent eye gaze using high-interest objects, photos or symbols
    • It can be very challenging to achieve calibration for individuals with RTT – go slow, and don’t be discouraged. It takes time to learn how to activate buttons using eyegaze
    • Begin slowly using high-interest activities
    • Trial a device before recommending a purchase (as you would with other clients)
    • Remember that one system won’t work in all contexts, so explore multiple communication options

Working with individuals with RTT and their families can be challenging yet highly rewarding! We can learn so much about alternative ways to meaningful communication with this population. As one family said, “these girls have so much to say if we only listen”.

Any questions – please contact me at: theresa.bartolotta@shu.edu

References/Resources

Bartolotta, T.E. & Remshifski, P.A. (2013). Coaching communication partners: A preliminary investigation of communication intervention during mealtime in Rett syndrome. Communication Disorders Quarterly, 34(3), 162 – 171.

Communication Matrix – http://www.communicationmatrix.org

Djukic, A. & McDermott, M.V. (2012). Social preferences in Rett syndrome. Pediatric Neurology, 46, 240-242.

Djukic, A., McDermott, M.V., Mavrommatis, K., & Martins, C.L. (2012). Rett syndrome: Basic features of visual processing – a pilot study. Pediatric Neurology, 47, 25-29.

International Rett Syndrome Foundation – http://www.rettsyndrome.org

Sigafoos, J., Arthur-Kelly, M. & Butterfield, N. (2006).Enhancing everyday communication for children with disabilities. Baltimore, MD:Brookes.