**3. The KomHIT-model using AAC during assessment and intervention within neuropsychiatry**

#### **3.1. Implementation of the model**

The department that was involved in this study is part of the neuropsychiatric clinic at Queen Silvia children's hospital, a regional specialist hospital for children and adolescents in Sweden. This clinic mainly performs assessments and medical interventions for children and adoles‐ cents with suspected and diagnosed neuropsychiatric disorders. The main task of this particular department or team is to assess young (pre-school-aged) children, where the majority of the children have pervasive problems with communication. Due to the strong hereditary factor in neuropsychiatry several parents also have problems with communication. A comparatively large amount of the families also have another language and/or cultural background that complicates the understanding of information, instructions and also the health care system and Swedish society generally.

Two team members from this department, a speech-language therapist and a special educator, was enrolled in the development of the KomHIT model and was provided with the commu‐ nication mentor education described above. In collaboration with the head of the department the planning of implementation was done. They started off by informing the staff about the overall purpose and methods of the KomHIT intervention and that they wanted to interview everyone about their processes, the need of pictorial supports and the design of these. After completing these interviews the designing of the supports or tools were done according to the wishes and ideas of the different team members.

The mentors had the opportunity to convene the staff to a kick-off – a half-day of training, going through convention texts, AAC methods and showing video clips of AAC-use in clinical situations. Each professional was provided with a folder with his/her own set-up of tools; visual schedules and dedicated communication boards and exercised the use of these in role plays. The two communication mentors also presented the general tools of the department; invitation letters with pictorial support, communication boards and visual schedules for waiting room communication, play activities and toilet visits, and finally visual support for identifying the different rooms. The materials that were developed are listed in the table below (table 1) and examples of these are displayed (figure 2).

The staff was asked to start the use of the visual tools and point talking immediately after the kick-off or as soon as possible. They were informed about the evaluation activities, a survey and a group interview, that was about to take place two months later and that it was important that they could participate in these.

#### **3.2. Pictorial supports and examples**

during the intervention phase no statistical analyses could be done. The results were promising in that the morning cortisol levels were lower in the group of children who were provided with AAC and that none of these children were in need of premedication. No differences were seen in regard to the STAI results. It was discussed that this might be due to the adapted STAI being too rough a measure. In conclusion this pilot study indicated that the use of pictures can reduce anxiety in children with communicative disability during hospital care, but that more

**Figure 1. Examples of tools used within day surgery.** To the left the visual schedule book of six pages depicting a vertical column of five photos on each side. The child removes the pictures one-by-one after finishing the different steps. This book was used for all children 2-8 years old and for older children with disability or language problems and/or being tense or anxious. The picture to the right shows a communication board that was used with children who

A pilot study of this intervention was conducted focusing on the expected decrease in stress and anxiety [22]. Twenty-five children with communicative disability (about half on the autism spectrum) and their parents participated (seven in the intervention group, 18 controls). Children and parents were asked about their emotional state using the State-Trait Anxiety Inventory (STAI), for children adapted to the Talking Mats format, and samples of saliva were collected. Premedication was also checked. Due to the few participants that could be recruited during the intervention phase no statistical analyses could be done. The results were promising in that the morning cortisol levels were lower in the group of children who were provided with AAC and that none of these children were in need of premedication. No differences were seen in regard to the STAI results. It was discussed that this might be due to the adapted STAI being too rough a measure. In conclusion this pilot study indicated that the use of pictures can reduce anxiety in children with communicative disability during

about the hospital visit, and to bring the visual schedule along during the travel to the hospital. Upon arrival to the surgery ward the nurse used point talking to the pictures in the Schedule book explaining the procedures of the day. The child then could bring this book along during the day and remove the pictures one-by-one after finishing the different steps. Each nurse also had access to the same "day surgery communication board" as was sent to the family (to the right above), to be able to expand point talking beyond the book, specifically for children with more comprehensive

**Figure 1 Examples of tools used within day surgery.** To the left the visual schedule book of six pages depicting a vertical column of five photos on each side. The child removes the pictures one-byone after finishing the different steps. This book was used for all children 2-8 years old and for older children with disability or language problems and/or being tense or anxious. The picture to the right shows a communication board that was used with children who needed more support during

The following parts of this chapter describes the implementation and evaluation of the KomHIT-model in a Neuropsychiatric clinic, using AAC in the form of pictorial supports

The following parts of this chapter describes the implementation and evaluation of the KomHITmodel in a Neuropsychiatric clinic, using AAC in the form of pictorial supports during assessment

hospital care, but that more research is needed to prove this [22].

**3. The KomHIT-model using AAC during assessment and intervention**

The department that was involved in this study is part of the neuropsychiatric clinic at Queen Silvia children's hospital, a regional specialist hospital for children and adolescents in Sweden. This clinic mainly performs assessments and medical interventions for children and adoles‐ cents with suspected and diagnosed neuropsychiatric disorders. The main task of this particular department or team is to assess young (pre-school-aged) children, where the majority of the children have pervasive problems with communication. Due to the strong hereditary factor in neuropsychiatry several parents also have problems with communication.

research is needed to prove this [22].

and intervention procedures.

communication problems.

information and conversation.

296 Autism Spectrum Disorder - Recent Advances

**within neuropsychiatry**

**3.1. Implementation of the model**

during assessment and intervention procedures.

needed more support during information and conversation.

The materials that were developed are listed in the table below (table 1) and examples of these are displayed (figure 2).



**Table 1.** List of pictorial material that was developed on the Neuropsychiatric clinic

Meeting the Communicative Rights of People with Autism — Using Pictorial Supports During Assessment… http://dx.doi.org/10.5772/59838 299

**Type of material Aim/name Short description**

Small specific speech-language

Welcome instructions

Symbols/pictures for visual

**Table 1.** List of pictorial material that was developed on the Neuropsychiatric clinic

marking-up

therapy

Pictures to be used within the clinic's medication school where the children are taught how to manage their

communication/conversation and other more specific tools

Smaller board to be used more specifically during speech-

Text and illustrating pictures to welcome patients and parents and provide instructions (available in different

consequences of not cancelling booked appointments

Symbols/pictures for marking-up rooms an functions on

formats for the different waiting-rooms)

medications

ADOS Pictures to support procedures and instructions in regard to ADOS assessment Speech-language therapist Pictures to support procedures and instructions in regard to assessment and intervention Psychologist (figure 2) Pictures to support procedures and instructions in regard to assessment and intervention Literacy testing Pictures to support procedures and instructions in regard

Large general (figure 3) Larger board that could be used generally to support

Small general Smaller board that could be used generally to support communication/conversation

language therapy visits Doctor's bunch (figure 3) A bunch of small boards to be used by the doctor to

Specific doctor and nurse board Two smaller boards to be used more specifically during medical visits

Schedule for toilet Visual schedule for toilet procedures, available in two formats: less and more detailed

Missed appointments Text and illustrating pictures to inform about

the clinic

Car play Board to support car play communication Doll play Board to support doll play communication Duplo play Board to support duplo play communication Garage play Board to support garage play communication Play House Board to support Play house communication Reading story books Board to support story book reading Choosing play activity Board to support pay and choice-making Waiting room Board to support waiting-room communication Cloak room Board to support cloak room communication Schedule for clothing Visual schedule for taking on/off clothes

to assessment of reading and writing

support communication/conversation

Medication school

298 Autism Spectrum Disorder - Recent Advances

**Communication board**

**Waiting room/ environment**

Figure 3. Examples of the pictorial materials listed above. To the left a general communication board to be used in different situations. To the right a bunch of boards dedicated for the physician. **Figure 2.** Examples of the pictorial materials listed above. To the left an invitation to the child. To the right a visual schedule for an assessment session. More material are available at www.kom-hit.se

**4. Evaluation and results**  The evaluation was done through a survey distributed to staff and parents at the department and through a group interview with staff members. The survey was part of the general evaluation **Figure 3.** Examples of the pictorial materials listed above. To the left a general communication board to be used in different situations. To the right a bunch of boards dedicated for the physician.

activities that was completed on all clinics involved in KomHIT and will not be reported here. The group interview used a semi-structured format along the lines of focus group methodology (Wibeck, 2010) and a content analysis of the transcripts was carried out to identify categories and main themes

The participants in the focus group study was recruited from the department working with young preschool aged children on the child neuropsychiatric clinic at Queen Silvia Children's Hospital, a regional specialist hospital in Sweden. This department was selected since the vast majority of the patients had communicative problems, were in need of communicative support that was only occasionally provided before the intervention started. An invitation letter with information about the interview was distributed to the entire staff at the department. A group of six staff representing five

professions was recruited. Participant data is presented in table 2.

Participant Gender Profession P1 ♂ Physician

(Graneheim & Lundman, ?).

**4. 1 Participants** 

**Table 2. Participants** 
