Aphasia and AAC

SLA G304

Shelley Weiss, MS CCC-SLP

Aphasia

• Aphasia: An acquired communication disability, usually a result of stroke or head injury, that affects symbolic language processing across modalities (after Schuell)

• Deficits in auditory comprehension, reading, writing, speech

Aphasia

• Apraxia: Impairment in ability to program, sequence and execute purposeful gestures, despite intact mobility–Oral–Limb

• Test of Limb and Oral Apraxia (Helm-Estabrooks)

Aphasia

• Candidacy for AAC strategies in aphasia

– a) those who find speech inadequate or inefficient in certain instances

– b) those who do not regain sufficient natural speech for communication of basic needs (after Hux, Beukelman, and Garrett, 1994)

Aphasia

• Revised Candidacy Classification system (Garrett and Beukelman)–Basic Choice Communicator –Controlled Situation Communicator–Comprehensive Communicator–Specific Needs Communicator–Augmented Input Communicator

Basic Diagnostic Protocol

• Assessment custom tailored

• Completed over extended period of time

• Across environments and communication partners

• Assessment and intervention occur simultaneously

• Interdisciplinary team

Interdisciplinary Assessment Team

• Physical therapist• Occupational therapist• Speech-language pathologist• Neuropsycologist• Physiatrist• Rehabilitation technician

Criteria-based Assessment

• Observe current level of function• Observe changes over time

–More effective than norm referenced–More sensitive to change over time–Time efficient

Criteria-based Assessment

• Skills assessment• Communication needs inventory• Opportunities and constraints• Feature matching• Trial period

Skills Assessment

• Diagnosis and prognosis• Motor function• Vision, hearing• Sensory, perceptual• Motor speech• Language• Communication, pragmatics• Cognition, behavior, psychosocial

Communication Needs Inventory

• Present and future needs• Four functions of communication

(Light, 1988)– Information transfer–Social closeness–Basic wants and needs–Social etiquette

Opportunities and Constraints Assessment

• Adjustment to the disability• Stage of recovery• Changing skill levels• Multiple communication partners

Opportunities and Constraints Assessment

• User environment (partner attitudes towards AAC)

• Availability of technical support• Medical protocol• Financial resources• Communicative desire, motivation

Feature Matching

• No single strategy or tool will have all features to meet user’s needs

• Flexibility of system is greatest consideration

Trial period

• Need adequate time to teach system• Implement in natural contexts• Re-assess• Modify• Re-assess• Mass Medicaid funds device trial

periods

Demands of Communication for Person with Aphasia for basic needs conversation (Garrett, 1996)

• Self aware• Generate an action plan• Generate a conceptual representation• Be attentive to environment • Posses an expressive modality• Sufficient working memory • Adequate semantic mapping/translation skills • Pragmatic skills to determine if message is received accurately• Metacommunicative ability to revise, repair

Aphasia: Demands imposed by AAC strategies (Garrett, 1996)

• Alternate physical access• Novel symbol translation• Sufficient working memory to complete

preceding symbol translation skills before forgetting the intent

• New operational skills for technology

Aphasia: General Intervention Strategies

• Communication access and success is intermittent in aphasia. Use what works from moment to moment

• Rely on residual world knowledge• Keep physical access demands simple• Keep visual display simple

Aphasia: General Intervention Strategies

• Carefully inventory communication needs using Light’s (1988) model

• Develop strategies to participate with peer group–Play Bingo–Tell jokes–Reminisce–Share opinions

Aphasia: General Intervention Strategies

• Assess most effective means and organization of representation–Visual spatial (maps, rating scales)–Categorical

• words, messages• pictures

–Topical

Aphasia: General Intervention Strategies

• Practice strategies in situational role-plays

• Family, important communication partners play a critical role in therapy

Aphasia Intervention: Remnant Book

• Basic choice,controlled situation, comprehensive communicator

• Mementos, remnants, photographs• Content is concrete, salient and unique

to user• Capitalizes on residual world

knowledge

Aphasia Intervention: Remnant Book

• Vehicle for sharing information, social closeness

• No expectations for regulating behavior• Promotes topic generation and

initiation for user and partner• Stimulates appropriate voluntary motor

response: page turning, pointing

Aphasia Intervention Remnant Book

• Emotionally salient content may stimulate user input/output modalities

• Doesn’t look like augmentative communication aid

• Primes user and family for future AAC systems

Aphasia: Remnant Book Study Results

– (Weiss, S., Ho, K., Garrett, K., Lloyd, L., 1999)

Conversational support in the form of topical, personalized communication books, regardless of symbolic representation facilitated the communication

Aphasia: Remnant Book Study Results

Remnants superior to pictographic symbols for: establishing joint attention maintaining conversational control communication partner ratings of

comfort and efficacy

Aphasia Intervention: Communication book• Inventory messages using Light’s model

• Visual: Simple symmetrical organization, layout to compensate for field cuts, neglect

• Obvious categories, tabs to mark pages

• Directions to communication partner

• Remnant section, maps, calendars, clocks, letter boards, rating scales

Aphasia Intervention: Communication book

• Decrease cognitive-linguistic demands–Teach in structured choice making–Revise partners’ expectations of PWA

self initiation• Teach partner to structure environment• Identify opportunities to make choice

Aphasia Intervention: Written Choice (Garrett, 1993)

• Partner provides written choices in context of conversation

• Possible responses anticipated and written in list form

• PWA selects correct response by pointing• Creates successful interaction• Good for sharing information, social

closeness

Aphasia: Tool Box

• Alternative symbol boards, books• Retractable key chain• Remnant book• Maps, calendars, rating scales, clocks

Aphasia: Tool Box

• Dedicated VOCAs– Simple: Macaw, MessageMate,

Cheaptalk–Complex: Dynamyte, Dynavox

• Computer-based: Speaking Dynamically, C-Speak Aphasia