Non-verbal Patients Can Speak Up

(Keynote speech given at the National Student Speech Hearing Language Association conference, Cleveland State University, October 2013) 

Non-verbal Patients Can Speak Up

Thank you, Allison, for the introduction.  I am Rosemary Musachio, and I am very honored to be invited as the keynote speaker at the National Student Speech Language and Hearing Association Conference.  As you might have guessed, I'm not here to talk about the latest techniques in speech therapy.  Instead, the C S U Speech and Hearing Program invited me to talk about my life as a nonverbal communicator. 

 I am an accessibility electronic and information analyst for a Boston- based company called Interactive Accessibility.  I have been in this line of work for twelve years with different companies.  An accessibility analyst tests websites and software to determine if persons with disabilities can use them.  For example, since someone with dexterity impairments, such as yours truly, cannot use a mouse to reach and click links, then we have to use the tab and enter keys.  That is one of the objectives I test regarding websites.  I also check if a website or software applications are compatible with screen readers, an assistive technology used by persons with vision impairments.  If a code of a website is not correctly structured, then the screen reader may be seen as gibberish.  Besides analyzing, I also blog on these issues and new assistive technology.

Now I would like to tell you about my life and its challenges.  My inability to speak is due to C.P, known as cerebral palsy.  I was born in Italy.  As legend has it, the doctor bumped my head as he was delivering me, which damaged my brain and caused cerebral palsy.    As you can see, besides speech, the C.P. has affected my ability to walk and perform tasks with my hands.  Fortunately, my ability to think, to create, to feel, and to dream, has not been impacted.

In fact, many of my dreams have been realized.  Besides graduating from C S U and traveling to many countries, I also experienced another kind of flying--hang gliding at five thousand feet. The experience was so very liberating, as was riding a motorcycle and riding horses.  Finally, I have been able to become a productive member of society by landing jobs and freeing myself, in part, from social security.  If you would like to read about some of these experiences, you may access my blog, Challenges of Everyday.

Like many children who have speech impairments, I started taking speech therapy at the United Cerebral Palsy nursery school.  All I remember is the speech therapist sticking a tongue depressor, with red gel on it in my mouth, pushing my tongue in different ways.  Did she really expect me to talk after she made my tongue so sore?

Speech therapy continued when I attended Sunbeam School.  I took two thirty-minute sessions a week for ten years.   At first, Mrs. Gordon, the therapist, would have me practice sounds and oral exercises, which I could not do.  My father helped me do these exercises.  I could only produce the “m” sound, just like a toddler saying “Mama.”  So I had a delay of three to four years saying the first sounds a child makes.

Mrs. Gordon realized that I could not coordinate my tongue and lips to verbalize anything intelligible.  Fortunately, she concentrated on helping me communicate through other means.  Until then, I used hand and eye gestures to communicate, mostly with my parents.   For example, if I had to go to the bathroom, I would point to my pelvic region.  If I wanted to go out, I would keep turning my head to look out the window.  I still use these signs with my mother. 

To help me communicate more than basic needs, Mrs. Gordon created an E-tran chart.  It was my first method of communicating with the world.  The layout of the E-tran chart was based on my lack of pointing ability.  it had six groups of letters and numbers.  Each group had a big letter on top and smaller letters below it.   As I struggle to remember, spelling a word meant positioning my hand on where each letter was in the group.  You can imagine how difficult it was to just spell cat.

Eventually, my speech therapist discovered that the lower knuckle of my right thumb stuck out when I made a fist, thus we discovered a faster pointing method.  Around this time, she also learned about Blisssymbols.  Created by a prison inmate in Canada, Blisssymbols were like hieroglyphics but with rationales, so children with learning disabilities could remember them.  Each Blisssymbol had its associated word above it, allowing persons unfamiliar with the system to read the word.  Blisssymbols came in sheets of one hundred, two hundred, four hundred and eight hundred symbols.  It also included the alphabet so I could spell any word that was not on the board.  My speech therapist would cut and paste a sheet to a game board to be folded and placed in my book bag.  To this day, I still use a version of the bliss board, only without the symbols.

When I spell something on my word board, I like the person with whom I am communicating to guess what I am trying to say after a few letters.  It saves much time and energy.  When people guess correctly, I feel like Bob Barker and want to offer them a prize.  Slower guessers make me mentally roll my eyes and think, “Don't they have it yet?”  Nevertheless, I am lucky if people are willing to read what I point to on the word board or even that I am able to communicate at all.

I completely understand when kids stare at me and, in their innocence, ask me why I am in a wheelchair.  Children may not have learned about human diversity yet.  However, when an adult starts talking to me too loudly and enunciating slowly, like I'm hard of hearing, or addressing things to my mother only, like I'm not there, I cannot spell out the word weirdo on my word board quick enough.  I love the look on their faces when my friend or my mother stuns them by announcing that I have a  B.A.  in Communication and that they should talk to me directly and stop yelling, so I don't assume they are crazy and roll myself away.  It is even better when a friend tells them I am a successful accessibility analyst. 

Although I often use humor to cope with people’s reactions toward my disabilities, sometimes they anger or frustrate me.  Instances when my frustration reaches its limit can happen at the doctor's office or in the hospital.  Three years ago I was hospitalized twice for pneumonia.  The communication barrier played a major role in both hospital stays being dreadful.  Once again, although my mother and friends told doctors and nurses that I am intelligent, that I graduated from C S U and I work as an accessibility analyst, the staff still talked to me as if I was cognitively challenged.  My friend posted a sign above my bed that I can comprehend everything and how to communicate with me.  This method proved to be mostly futile.  Their presumption possibly prevented them from interpreting my gestures and vocal cues.  For example, when I could not reach the call button, I would often yell out, hoping someone would come.   Many times my calls went unanswered.  When someone did arrive and asked me what I wanted, I would look at my pillow and point to it, indicating that I wanted it raised or needed to be lifted up higher in the bed.  I did not know how else to communicate these needs to them.  Some nurses and aids did not observe that my head was five inches away from the pillow and could not understand my “yes” and “no” responses.

Alleviating the obstacles that I, along with other nonverbal patients, have faced is as much our responsibility as it is the doctors, nurses, and, yes, speech therapists.  Besides a sign saying that we fully comprehend language, such as the one posted above my bed, nonverbal patients also should have booklets or chart that include basic information about the individual and their augmentative assistive communication (AAC) techniques.  This information should be placed in clear view near the hospital bed and in the medical record for future reference.  For instance, I have an information chart that I always carry in my bag.  It has an explanation of how I communicate with my word board, my eyes, and vocal sounds.

As shown with my hospital experiences, informing a nonverbal patient's medical team about AAC methods does not always serve its purpose.  While nurses on the morning shift know that the patient raises her eyes for affirmative responses, the night shift may be oblivious of this detail.  Patient nurse ratio is another factor that can undermine understanding communication cues.  When a nurse or aide has ten or more patients to attend to, taking the time to decipher a patient's gestures can be difficult unless an interpreter or speech pathologist is there to assist.

Successful interaction between nurses and nonverbal patients is based on the nurses desire to communicate with them.  Despite being in a profession where they are likely to work with persons with disabilities, some nurses still may have miss conceptions.  When a nonverbal patient is admitted into the hospital, that reoccurring assumption pops up that he is deaf or cannot understand.  Therefore, any attempt from the patient to communicate may be overlooked or ignored.  According to a study in 2004, patients on mechanical ventilation have more difficulty communicating with nurses who were robotic, inattentive, and absent from the bedside.  Conversely, communication becomes less frustrating when nurses are kind, physically present, and informative.  It is like that with anyone, not just nurses.  If someone sits five feet from me and is mute, chances are that this person does not want to read my word board no matter how much I bang on it.  In fact, it hinders me from wanting to  communicate with the individual, for I browse through thoughts in my mind, thinking of what  to say to them, and come up with nothing.  Even when I am in a car where I cannot use my word board, I become nervous if the driver or other passengers are not talking.  For me, it compensates for my inability to speak.

It is very important to educate nurses, staff and nursing aides to understand non-verbal patients and their level of pain.  For instance, a course is offered at Suburban Hospital in Bethesda, Maryland for nurses to learn to recognize pain in non-verbal patients based on facial expression, restlessness, vocal sounds, muscle tone and the ability to console.  Therefore, if a non-verbal patient were in extreme pain, he would express it in one or more of the following ways: frown, moan, rigid limbs, inability to stay still, or inability to accept verbal or tactile consolation.  Forgive me, but don't these cues seem obvious? It seems that people depend on communicating via technology and have forgotten how to communicate in person.  I give the Bethesda course credit because it encourages participants to find communication tools for their non-verbal patients.

Speech pathologists in Boulder, Colorado have a more comprehensive strategy in helping non-verbal patients to communicate more effectively.  They developed the On The Spot Communication Toolkit.  This first aid kit for communication contains word and picture boards in different languages, adapted call bells for patients who cannot reach or press standard call bells, writing boards, and pocket talker amplifiers for the hearing impaired.  If any of you would like to know where to purchase the toolkit, let me know and I will send you the link. This toolkit is up there with the invention of the wheelchair. Having the toolkit available, however, does not necessarily mean any of the medical staff will use it or will know how to use it.  Hospitals should provide mandatory training to their employees on how to implement the toolkits.  It is important that the adapted equipment be easily reached by the patient at all times.  The training can include differences between word versus picture boards, amplification resources for the hearing impaired, and where to place the adapted equipment, including call bells that are reached easily.  Just a personal aside about call bells, because my call bell was in the same unit as the television remote buttons, I often pressed the call button by accident.  This prompted one nurse to put the control unit out of my reach.  When I actually had to use the call bell, I had to yell at the top of my lungs instead.

As I mentioned, the On The Spot Toolkit includes word boards, otherwise known as EZ Boards, for different hospital settings.  The ICU boards include a pain chart that shows words for pain levels, discomfort types, and personal hygiene.  Each board has the alphabet so patients can spell words.  These boards are inexpensive and hospitals could purchase them for each floor unit.

To help non-verbal patients use word boards more effectively, nurses can play the same guessing game that people do when I communicate with my board.  For example, if a patient points to the word bed, the nurse can guess if he wants his bed raised before he spells it out.  Additionally, practitioners should position the patient differently if he cannot reach the board or cannot gesture effectively.  It is important to have the nonverbal patient sitting up, so gravity works in their favor.  Another good practice is to ask close-ended or multiple choice questions.  

Ineffective communication with non-verbal patients can worsen their conditions.  In fact, according to the joint commission on accreditation of healthcare organizations, sixty five percent of medical errors occur due to poor communication between the medical staff and patients.  However, when nonverbal patients can communicate more effectively, benefits appear.  They spend less time in the ICU, have lower blood pressure, and their respirations become more stabilized.  When nurses are aware of a nonverbal patient’s cues, they can identify alert gestures, such as repetitive eye gazes at an I.V., to indicate that a wrong medication is being administered. 

These communication strategies and techniques can be applied in any environment or situation, from airports and airplanes to shopping centers and restaurants.  It would be ideal if the Americans with Disabilities Act (ADA) would include a provision saying something like, “Every public entity shall train employees to facilitate communication with individuals that have communication impairments.”  I get annoyed when waiters ask my mother or friend, “What would she like to drink?”  They could be trained to follow my hand on the menu.  I have to say that many TSA agents in the airports have the good sense to ask me questions directly.

When I attended CSU, I had a voice synthesizer called the Light Talker.  Each button on the device could be activated with an infrared light.  Because I couldn't hold and manipulate the infrared light pointer, a rehab engineer created an iron-like object that I would drag across the surface and stop at the icon I wanted.  Tapping two picture icons were required to say a phrase.  For instance, I had to activate the SUN icon and the ELEPHANT icon to say, “I'm happy to meet you.”  These devices required users to have photographic minds to memorize all those combinations.  Often the Light Talker stopped working, sometimes in the middle of my forming a sentence. I would look helplessly at my listener until he or she finally understood that the stupid thing died.  This would also happen when the plug came out of the pointing device.  I used the Light Talker only at school, not at home.  Therefore, a low tech word board is more effective for my personal interactions. 

In the past five years AAC technology has surpassed my wildest dreams and expectations.  Look at the ipad.  Its apps offer hundreds of communication choices and opportunities.   Today, I am able to speak to all of you because I have a loner Maestro Dynavox, courtesy of the Cuyahoga County Board of Developmental Disabilities.  I sincerely thank Kathy Zielinski and Marsha Malla Med for giving me a loud voice to express my life's accomplishments in an independent manner to this group of future speech language pathologists. 

So, as future speech language pathologists, perceive your clients as individuals who think and feel, not as subjects to apply theories on.  If they have the cognitive ability, ask them what communication method would work for them, for their skills, for their lifestyle.  I hope you have gained insights on the barriers your future nonverbal patients or clients may face and how to help them overcome communication barriers.

I'd like to thank Sue Neff, Myrita Wilhite, Brigette Culiver, and Doreen Binnie for inviting me and all the students who volunteered to make this conference a success.  I would also like to thank my mother and friends who are all in the audience.  they are my daily motivation. If anyone has questions, ask away!

 

Speech as spoken by speech synthesizer

thank you allison, for the introduction.  I am rosemary musashio and i am very honored to be invited as the keynote speaker at the National student Speech language and hearing association conference. As you might have guessed, I'm not here to talk about the latest techniques in speech therapy. Instead, the C  S U speech and hearing program invited me to talk about my life as a nonverbal communicator. 

i am an accessibility electronic and information analyst for a boston based company called, interactive accessibility. i have been in this line of work for twelve years with different companies.  an accessibility analyst tests websites and software to determine if persons with disabilities can use them.  for example, since someone with dexterity impairments, such as yous truly, can not use a mouse to reach and click links, then we have to use the tab and  enter  keys.  that is one of the objectives i test regarding websites.  i also check if a website or software applications are compatible with screen readers, an assistive technology used by persons with vision impairments.  if a code of a website in not, however correctly structured, then the screen reader may be seen as gibberish.  besides analyzing, i also blog on these issues and new assistive technology.

now i would like to tell you about my life and its challenges.  My inability to speak is due to C P, known as cerebral palsy.  i was born in italy.  As legend has it, the doctor bumped my head as he was delivering me which damaged my brain and caused cerebral palsy.    As you can see, besides speech, the C P has affected my ability to walk and perform tasks with my hands. Fortunately, my ability to think, to create, to feel, and to dream, has not been impacted.

 
in fact many  my dreams have been realized.  besides graduating from c s u and traveling to many countries, i also experienced another kind of flying, hang gliding at five thousand feet.  the experience was so very liberating, as was riding a motorcycle and riding horses.  finally, i have been able to become a productive member of society by landing jobs and freeing myself, in part, from social security.  if you would like to read about some of these experiences, you may access my blog, challenges of everyday.

like many children that have speech impairments, i started taking speech therapy at the united cerebral palsy nursery school.  all i remember is the speech therapist sticking a tongue depressor, with red gel on it in my mouth, pushing my tongue in different ways.  did she really expect me to talk after she made my tongue so sore?

 
speech therapy continued when i attended sunbeam school.  i took two thirty minit sessions a week for ten years.  at first, misses gordon, the therapist, would have me practice sounds and oral exercises, which i could not do.  my father helped me do these exercises.  i could only produce the m sound, just like a toddler saying mama.  so i had a delay of three to four years saying the first sounds a child makes.

misses gordon, realized that i could not coordinate my tongue and lips to verbalize anything intelligible.  fortunately, she concentrated on helping me communicate through other means.  until then, i used hand and eye gestures to communicate, mostly with my parents.  for example, if i had to go to the bathroom, i would point to my pelvic region.  if i wanted to go out, i would keep turning my head to look out the window.  i still use these signs with my mother. 

to help me communicate more than basic needs, misses gordon created an ee tran chart.  it was my first method of communicating with the world.  the layout of the e tran chart was based on my lack of pointing ability.  it had six groups of letters and numbers.  each group had a big letter on top and smaller letters below it.   as i struggled to remember, spelling a word meant positioning my hand on where each letter was in the group.  you can imagine how difficult it was to just spell cat.

  eventually, my speech therapist discovered that the lower knuckle of my right thum stuck out when i made a fist, thus we discovered a faster pointing method.  around this time, she also learnes about bliss symbols.  created by a prison inmate in canada, bliss symbols we like hieroglyphics but with rationales, so children with learning disabilities could remember them.  each bliss  symbol had its associated word above it, allowing persons unfamiliar with the system to read the word.  bliss symbols came in sheets of one hundred, two hundred, four hundred and eight hundred symbols.  it also included the alphabet so i could spell any word that was not on the board.  my speech therapist would cut and paste a sheet to a game board to be folded and placed in my book bag.  to this day, i still use a version of the bliss board, only without the symbols.

 when i  spell something on my word board, i like the person with whom i am communicating to guess what i am trying to say after a few letters.  it saves much time and energy.  when people guess correctly, i feel like bob barker and want to offer them a prize.  slower guessers may me mentally roll my eyes and think, don't they have it yet.  nevertheless, i am lucky if people are willing to read what i point to on the word board or even that i am able to communicate at all.

  i completely understand when kids stare at me and, in their innocence, ask me why i am in a wheelchair.  children may not have learned about human diversity yet.  however, when an adult starts talking to me too loudly and enunciating slowly, like i'm hard of hearing, or addressing things to my mother only, like i'm not there, i can not spell out the word weirdo on my word board quick enough.  i love the look on their faces when my friend or my mother stunz them by announcing that i have a  Be ay in communication and that  they should talk to me directly and stop yelling, so i don't assume they are crazy and roll myself away.   it is even better when a friend tells them i am a successful accessability analyst. 

 although i often use humor to cope with peoples reactions toward my disabilities, sometimes they anger or frus trate me.  instances when my frustration reaches its limit can happen at the doctor's office or in the hospital.  three years ago i was hospitalized twice for pneumonia.  the communication barrier played a major role in both hospital stays being dreadful.  once again, although my mother and friends told doctors and nurses that i am intelligent, that i graduated from C S U and  i work as an accessability analyst.   the staff still talked to me as if i was cognitively challenged.  my friend posted a sign above my bed that i can comprehend everything and how to communicate with me.  this method proved to be mostly futile.  their presumption possibly prevented them from interpreting my gestures and vocal cues.  for example, when i could not reach the call button, i would often yell out, hoping someone would come.   many times my calls went unanswered.   when someone did arrive and asked me what i wanted, i would look at my pillow and point to it, indicating that i wanted it raised or needed to be lifted up higher in the bed.  i did not know how else to communicate these needs to them.  some nurses and aids did not observe  that my head was five inches away from the pillow and could not understand my yes and no responses.

alleviating the obstacles that i, along with other nonverbal patients, have faced is as much our responsibility as it is the doctors, nurses, and, yes, speech therapists.  besides a sign saying that we fully comprehend language, such as the one posted above my bed, nonverbal patients also should have booklets or charts that include basic information about the individual and their augmentative assistive communication, ay ay C, techniques.  this information should be placed in clear view near the hospital bed and in the medical record for future reference.  for instance, i have an information chart that i always carry in my bag.  it has an explanation of how i communicate with my word board, my eyes, and vocal sounds.

  as shown with my hospital experiences, informing a nonverbal patient's medical team about ay ay C methods does not always serve its purpose.  while nurses on the morning shift know that the patient raises her eyes for affirmative responses, the night shift may be oblivious of this detail.  patient nurse ratio is another factor that can undermine understanding communication cues.  when a nurse or aide has ten or more patients to attend to, taking the time to decipher a patient's gestures can be difficult unless, an interpreter or speech pathologist is there to assist.

 
Successful interaction between nurses and nonverbal patients is based on the nurses desire to communicate with them.  despite being in a profession where they are likely to work with persons with disabilities, some nurses still may have miss conceptions.  when a nonverbal patient is admitted into the hospital, that reoccurring assumption pops up, that he is deaf or cannot understand.  therefore, any attempt from the patient to communicate may be overlooked or ignored.  according to a study in two thousand and four, patients on mechanical ventilation have more difficulty communicating with nurses who

were robotic, inattentive, and absent from the bedside.  conversely, communication becomes less frustrating  when nurses are kind, physically prezent, and informative.  it is like that with anyone, not just nurses.  if someone sits five feet from me and is mute, chances are that this person does not want to read my word board no matter how much i bang on it.  in fact, it hinders me from wanting to  communicate with the individual, for i browse through thoughts in my mind, thinking of what  to say to them, and come up with nothing.  even when i am in a car, where i can not use my word board, i become nervous if the driver or other passengers are not talking.  for me, it compensates for my inability to speak.

it is very important to educate nurses, staff and nursing aides to understand non-verbal patients and their level of pain. for instance, a course is offered at suburban hospital in bethesda, maryland, for nurses to learn to recognize pain in non-verbal patients based on facial expression, restlessness, vocal sounds, muscle tone and the ability to console. therefore, if a non-verbal patient were in extreme pain, he would express it in one or more of the following ways, frown, moan, rigid limbs, inability to stay still, or inability to accept verbal or tactile consolation. forgive me, but don't these cues seem obvious? it seems that people depend on communicating via technology and have forgotten how to communicate in person. i give the bethesda course credit because it encourages participants to find communication tools for their non-verbal patients.

speech pathologists in boulder, colorado have a more comprehensive strategy in helping non-verbal patients to communicate more effectively. they developed the on the spot communication toolkit.  this first aid kit for communication contains word and picture boards in different languages, adapted call bells for patients who can not reach or press standard call bells, writing boards, and pocket talker amplifiers for the hearing impaired. if any of you would like to know where to purchase the toolkit, let me know and i will send you the link. this toolkit is up there with the invention of the wheelchair. having the toolkit available, however, does not necessarily mean any of the medical staff will use it or will know how to use it. hospitals should provide mandatory training to their employees on how to implement the toolkits.  it is important that the adapted equipment be easily reached by the patient, at all times.   the training can include differences between word versus picture boards, amplification resources for the hearing impaired, and where to place the adapted equipment, including call bells that are reached easily.  just a personal aside about call bells, because my call bell was in the same unit as the television remote buttons, i often pressed the call button by accident. this prompted one nurse to put the control unit out of my reach. when i actually had to use the call bell, i had to yell at the top of my lungs instead.

as i mentioned, the on the spot toolkit includes word boards, otherwise known as e z boards, for different hospital settings.  the i c u boards  include a pain chart that shows words for pain levels, discomfort types, and personal hygiene. each board has the alphabet so patients can spell words.  these boards are inexpensive and hospitals could purchase them for each floor unit.

to help non-verbal patients use word boards more effectively, nurses can play the same guessing game that people do when i communicate with my board.  for example, if a patient points to the word bed, the nurse can guess if he wants his bed raised before he spells it out.  additionally, practitioners should position the patient differently if he can not reach the board or can not gesture effectively.  it is important to have the nonverbal patient sitting up, so gravity works in their favor.  another good practice is to ask closed ended or multiple choice questions.   ineffective communication with non-verbal patients can worsen their conditions.  in fact, according to the joint commission on accreditation of healthcare organizations, sixty five percent of medical errors occur due to poor communication between the medical staff and patients.  however, when non verbal patients can communicate more effectively, benefits appear.  they spend less time in the i c u, have lower blood pressure, and their respirations become more stabilized.  when nurses are aware of a nonverbal patients cues, they can identify  alert gestures, such as repetitive eye gazes at an i v, to indicate that a wrong medication is being administered. 

these communication strategies and techniques can be applied in any environment or situation, from air ports and airplanes to shopping centers and restaurants.  it would be ideal if the americans with disabilities act, Ay D Ay, would include a provision saying something like, every public entity shall train employees to facilitate communication with individuals that have communication impairments.  i get annoyed when waiters ask my mother or friend, what would she like to drink?  they could be trained to follow my hand on the menu.  i have to say that many T S A agents in the airports have the good sense to ask me questions directly.

when i attended c s u, i had a voice synthesizer called the light talker.  each button on the device could be activated with an infa red light.  because i couldn't hold and manipulate the infared light pointer, a rehab engineer created an iron like object that i would drag across the surface and stop at the icon i wanted.  twenty years ago, tapping two picture icons were required to say a phrase.  for instance, i had to activate the SUN icon and the ELEPHANT icon to say, i'm hapy to meet you.  these devices required users to have photographic minds to memorize all those combinations.  often the light talker stopped working, some times in the middle of my forming a sentence. i would look helplessly at my listener until he or she finally understood that the stupid thing died.  this would also happen when the plug came out of the pointing device.  i used the light talker only at school, not at home.  therefore, a low tech word board is more effective for my personal interactions. 

 
in the past five years ay ay c technology has surpassed my wildest dreams and expectations. look at the eye pad.  its apps offer hundeds of communication choices and opportunities.   today, i am able to speak to all of you because, i have a loner maestro dynavox, courtesy of the cuyahoga county board of developmental disabilities.  i sincerely thank kathy zielinski and marsha malla med, for giving me a loud voice to express my life's accomplishments, in an independent manner, to this group of future speech language pathologists. 

so, as future speech language pathologists, perceive your clients as individuals who think and feel, not as subjects to apply theories on.  if they have the cognitive ability, ask them what communication method would work for them, for their skills, for their lifestyle.  i hope you have gained insights on the barriers your future nonverbal patients or clients may face and how to help them overcome communication barriers.

i'd like to thank sue neff, myrita wilhite, brigette culiver and doreen binnie for inviting me, and all the students who volunteered to make this conference a success.  i would also like to thank my mother and friends who are all in the audience.  they are my daily motivation. if anyone has questions, ask away!