By Patti Murphy
It is disheartening when a child is crying and cannot tell you why. Ask a school nurse, who is likely to witness this sort of thing on a regular basis. It can be especially tough with children who are nonverbal or whose speech is hard to understand.
School nurses see a different mix of kids every day. In 2010, the Health Resources and Services Administration reported that 73,697 registered nurses in the United States worked as school nurses, far outnumbered by their students. Nurses may not always know in advance when a student is identified as having CCN, or complex communication needs, or may not recognize it just by looking. Collaboration with the speech-language pathologist and other staff who see the child more is good practice. The mix of augmentative and alternative communication (AAC) solutions (high-tech devices, low-/light-tech tools such as static devices or picture books, or unaided techniques such as gestures) that work best for the child can vary depending on the circumstances, the level of support needed to implement the solution and how well they know their communication partners. Keeping everyone in the loop can only make solutions better.
While their experience with kids who use an AAC device ranges from daily to rare or none, nurses I’ve talked or emailed with easily named situations where the reason for a child’s tears could be clarified, in a timely way, through AAC device use. Parents, too, appreciate that the technology, combined with other AAC methods, lets their child be specific and independent when telling the nurse (or other adult) what’s wrong. Here are some examples:
Situation: The child may be getting sick but it is hard to know whether to keep them home.
Resolution: A mother saw that her preschooler seemed extra tired one morning. So on the way to school, she asked the child to practice saying “I feel sick and need to go home” –a phrase the child automatically shared with her school aide later that day, avoiding guessing games and maybe an unnecessary visit to the nurse.
Situation: The child feels overwhelmed and simply needs a break.
Resolution: When children can’t say what’s bothering them, it often magnifies the problem. A change in routine, for instance, can trigger negative behavior in children with autism. Having age-appropriately phrased messages on their AAC device like “I need some space,” “Too much is happening at once,” “I don’t like surprises,” or “Can I have a time out, please?” is important. It is empowering for the young person to have a voice in the matter. And it helps others to help them.
Situation: The child has physical pain they cannot describe.
Resolution: Give them words that go beyond “It hurts” or “I have a headache” to make sure others get it. AAC devices offer descriptive vocabularies for health-related issues, allowing the child to say where it hurts and whether the pain feels sharp, dull, or like pins and needles. They can tell you whether bumping into an object may have caused the discomfort or how to reposition them in their wheelchair so they feel comfortable again.
Situation: The child fears that he/she may be getting a shot during a routine height, weight, vision and hearing screening.
Resolution: One mom says her son, who has autism, likes to know when he’s about to get a shot and uses his device to ask. He is more at ease on family doctor and dentist visits, too, because he can be specific about his concerns. In addition to choosing from the many pre-programmed messages on his device, he types novel ones on its onscreen keyboard, which has helped him taper his habit of simply repeating what he thinks others want him to say when asked how he feels.
Such situations usually involve multi-modal communication occurring with or without the aid of a device. The child, realizing that an adult understands his/her concerns or starting to feel better, may smile or give a fist bump. They may stay close, or even tap the adult on the shoulder, if they have more to say. To stay on topic, the child may point to pictures or printouts of content from their AAC devices, or blend device use with verbalization of familiar words. Some children have a system of blinking their eyes once for YES, twice for NO, fast when they have exciting news or slowly to show that they’re listening. Others hold up their right or left and to give a specific message, or do finger spelling. Team members can be creative. One nurse shared that some children respond best during hearing exams by tossing clothespins in a bucket when they hear sounds.
Nurses like when a child to conveys information instead of relying on an aide to do so. True, aides often spend more time with the child than anyone else at school. They may be the best interpreters of a child’s non-verbal expression and the main device programmers. But the aide may be a substitute or busy with another child. There is less continuity in districts where aides change from year to year.
It is important to let children do their own talking, no matter how they do it. Conversations with the school nurse or similarly infrequent—but vital—communication partners teach self-care. That’s a truly valuable skill for all kids to learn while growing up.